Nursing Home Privacy Policy
Acknowledgment Form

Please read our Privacy Policy carefully to understand how we handle personal and health information. Sign and date this form to acknowledge your understanding and agreement with our Privacy Policy.

Personal Information

Full Name
Position		Department

Privacy Practices

• I understand that our organization takes the privacy of personal and health information seriously and has implemented measures to protect this information.

• I acknowledge that it is our responsibility to adhere to the guidelines set out in the Privacy Policy to ensure that information is handled appropriately.

• I am aware that the Privacy Policy provides information on my rights to access and control my personal information, including how to request access or corrections to my personal information.

Confidentiality Agreement

• I agree to maintain the confidentiality of all personal and health information that I may access during my association with our organization.

• I understand that unauthorized disclosure of personal information is against our policy and could lead to disciplinary action, termination of my relationship with the organization, or legal consequences.

Use of Information

• I agree that I will use personal and health information solely for the purpose of fulfilling my duties within our organization and as allowed by our Privacy Policy.

• I understand that any misuse or unauthorized use of personal information contrary to our Privacy Policy will be addressed according to our disciplinary procedures.

Reporting Violations

• I agree to report any suspected or known violations of our Privacy Policy to my supervisor or the designated privacy officer immediately.

[Date]

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