HIPAA Confidentiality Agreement Form
HIPAA Confidentiality Agreement Form
Please fill out the form below to complete the agreement.
Date of Agreement
Employer
Name
Address
Phone number
Employee
Name
Address
Phone number
Recipient's Obligations
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Confidentiality: The Recipient agrees to maintain the confidentiality of all PHI obtained during the course of their duties.
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Permitted Use: PHI will only be used or disclosed as necessary to perform assigned duties, in accordance with HIPAA regulations.
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Safeguards: The Recipient will implement appropriate safeguards to prevent unauthorized use or disclosure of PHI.
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Reporting: Any unauthorized access, use, or disclosure of PHI must be reported immediately to the Covered Entity.
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Return or Destruction of PHI: Upon termination of the agreement or duties, the Recipient agrees to return or securely destroy all PHI in their possession.
Prohibited Actions
The Recipient agrees not to:
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Use or disclose PHI for personal gain.
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Share PHI with unauthorized individuals.
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Access PHI beyond their authorized role.
Acknowledgment and Agreement
By signing this Agreement, the Recipient acknowledges understanding their responsibilities under HIPAA and agrees to comply fully with its requirements.
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Recipient
Name: Date: |
Employer
Name: Date: |
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