Northridge Confidentiality Hipaa Form PDF Details

The Northridge Confidentiality HIPAA form, utilized by the Klotz Student Health Center (SHC), presents a clear mandate towards the safeguarding of personal health information (PHI) of patients. Individuals engaged with the SHC, either through employment or association, are brought under an imperative pledge to adhere to strict confidentiality protocols particularly designed to uphold the privacy and security of patient information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Essentially, this form is an agreement that confirms an individual’s commitment to access patient data solely for legitimate, necessary reasons relevant to their job or association duties. Moreover, it underscores the obligation not to divulge, communicate, or misuse any patient data beyond what is essential for the delivery of contracted services. An interesting aspect of the form is that it includes provisions for the release of information within the boundaries of contracted services to only those who have also committed to confidentiality via official agreements and demonstrate a legitimate need for the information. The form also clearly informs signatories that their responsibilities regarding patient information confidentiality will extend beyond the cessation of their employment or association with the SHC. Furthermore, it signals the severe repercussions of unauthorized use or disclosure of patient information, including potential termination, fines, or even incarceration, thereby emphasizing the gravity and importance of compliance with these stipulations. This reflective agreement not only serves as a stern reminder but also as a legal boundary for those interacting with personal health data within the health center, underscoring the foundational principle that patient information is a privilege to handle with the utmost respect and care.

QuestionAnswer
Form NameNorthridge Confidentiality Hipaa Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshipaa confidentiality agreement, hipaa acknowledgement templates for counseling, hipaa agreement example fo massage, hipaa business agreement

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KLOTZ STUDENT HEALTH CENTER

Pledge of Confidentiality

Personal Health Information/Patients

I, ___________________________________, understand the Klotz Student

Health Center policy on confidentiality of personal health information of our patients.

In regards to my employment or association with the Klotz Student Health Center (SHC) and as an integral part of the terms and conditions of my employment, I understand that personal health information belongs to the patient. I hereby agree and pledge that I will access only that patient data which is necessary to perform contracted responsibilities. I agree not to disclose, communicate, or use any patient information in any manner other than that necessary for the provision of the contracted services. Information within the scope of contracted services will be released only to those who have signed confidentiality agreements and have a need to know.

I understand that my obligation outlined above will continue after my employment or association with the Klotz SHC ends.

I also understand that unauthorized use or disclosure of such information may result in disciplinary action including, but not limited to, termination of my employment, fines, and/or incarceration.

My signature below attests to the fact that I have read, understand, and agree to abide by the terms of this agreement.

Name: _______________________________________________________

Signature:_____________________________________________________

Date: _________________

Witness signature:______________________________________________

Confidentiality HIPAA

LRC:mr 09/04/03: Forms Cmt. Revised by LRC 1/07

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