HIPAA Confidentiality Form

Please read this form carefully and sign to confirm your agreement.

Acknowledgement and Agreement

1. Confidentiality Obligations: I may have access to confidential PHI as part of my role.

2. Use and Disclosure of PHI: I will only use or disclose PHI as permitted by law, my job responsibilities, and company policies.

3. Safeguarding Information: I will take all reasonable steps to protect PHI from unauthorized access, use, or disclosure.

4. Reporting Breaches: I will immediately report any known or suspected breach of PHI to the designated compliance officer or supervisor.

5. Consequences of Non-Compliance: I understand that violations of HIPAA regulations or this agreement may result in disciplinary action, termination, and potential legal consequences.

By signing below, I confirm that I have read, understand, and agree to comply with the terms of this confidentiality agreement.

Name:

Date:

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