Northridge Confidentiality Hipaa Form PDF Details

Northridge Confidentiality Hipaa Form is a document that provides employees with guidelines for protecting the privacy of patients. Employees who handle confidential information must complete and sign the form to acknowledge their understanding of the policies and procedures related to patient privacy. Completing and signing this form is a requirement for all employees who work in a position where they may have access to patient information. By completing and signing this form, employees are agreeing to protect the privacy of all patients, abide by HIPAA regulations, and maintain the confidentiality of any information disclosed.

Below are some facts you may want to check just before you start using the northridge confidentiality hipaa form.

Form NameNorthridge Confidentiality Hipaa Form
Form Length1 pages
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

Form Preview Example


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: _______________________________________________________


Date: _________________

Witness signature:______________________________________________

Confidentiality HIPAA

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

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hipaa business agreement fields to fill out

Type in the appropriate information in My signature below attests to the, Name, Signature, Date, Witness signature, and Confidentiality HIPAA LRCmr Forms field.

Completing hipaa business agreement step 2

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