Whenyour

263
(On
Agreement
Dear
Employee,
people
letterhead)
about
comeconfidentiality
Confidentiality
to this practiceand
agreement
forprivacy
evaluation
forofemployees
healthcare
or treatment
information
of their or their
relatives or childrens mental health they are likely to discuss very personal info
rmation which they want to remain confidential - to be known only to themselves
and the therapist or clinician who is treating them. Some of this information ma
y be recorded on paper and/or into computerized records and so these records mus
t be treated with care. You, and every person who can access these records is be
ing trusted by the client to preserve the confidentiality of their information what the law calls their Protected Health Information or PHI. You should assume
Inthat
theeverything
pages belowisweconfidential
describe theinrules
this this
officeoffice
and treat
has created
it accordingly.
to do our best
to protect the confidentiality of all clients PHI and any other confidential info
rmation in this office. As a condition of your employment we require that you re
ad, understand, and agree to comply with these rules. However, there may be situ
ations not covered by these rules and we expect that you will appreciate the nee
d for privacy and take any extra steps or behave in a very cautious way in those
cases. If you are unsure what to do, always ask for guidance from your supervis
or or our privacy officer. When you are handling confidential information your c
areful read,
Please
effortsindicate
will beyour
appreciated.
having read by checking the boxes, ask any questions
you
You
Confidential
have,have
will
andInformation
agree totothe
access
several
following.
kinds of information which must be treated confi
qdentially.
Clients,
You maysuch
haveasaccess
their clinical
to information
(medical)
about:
records, intake information, f
inancial information, etc. All information about a clients care, treatment, histo
ry, or condition is confidential information. This extends to conversations you
qor othersEmployees,
have withvolunteers,
them.
or students such as their histories, salaries, em
qploymentThis
records,
practice,
disciplinary
such as its
actions,
financial
problems,
and statistical
etc.
records, strategic
plans, reports, memos, contracts, communications, proprietary computer programs
qor expect
We
technology,
Other
thatpersons
etc.willortreat
you
organizations
all information
and their
in this
property.
office as confidential and
Rules
qshareand
this
I agree
Behavioral
confidential
to respect
Examples
information
the officeonly
policies
with and
thoseprocedures
authorizedabout
to receive
maintaining
it.
qthe privacy
I will
of do
health
my best
caretoinformation.
prevent any unauthorized use or disclosure of any i
qnformation
I will
received,
not access,
storedread,
or used
review,
in this
copy,
office.
alter, remove, lend, or destroy a
ny file, report, or other form of PHI or other confidential information except a
qs part ofI will
my work
notduties
knowingly
herelet
andany
in false,
accord inaccurate,
with office or
policy
misleading
and procedures.
informatio
qn be included
I willinnotanyusefile
or let
or report.
others use any PHI or other confidential informati
qon for any
I wont
kind share
of personal
or disclose
benefitanytoinformation
me or them.about a client with any non-empl
oyee, my family, or my friends. I wont share any information which might allow a
qnon-employee
I wont
to discuss
identifyPHI
a client
or confidential
or clientsinformation
family. with another employee in a
ny area where clients or non-employees could overhear. I will remind other emplo
yees of this rule when it is or could be broken or take other steps to maintain
qthe privacy
I will
of not
thisinstall
information.
any software onto any computer in the office. I will
respect the ownership rights of the software I use at work. I will not make copi
es of software for my own use or distribution to others. I will not use any nonqlicensedIsoftware
accept responsibility for all activities which use my access method su
ch as a password, passphrase, access card, key or other device. I will not share
any of these with anyone else or allow anyone to access or alter information us
ing my access method. I will not try to access information using anyone elses acc
qess method.
I understand that my computer files or e-mail can be searched, without a
dvance notice, for business purposes, such as investigating theft, disclosure of
confidential business or proprietary information, personal abuse of the system
q, or monitoring
I understand
workflow
my access
or productivity.
privileges to PHI and other confidential informat
qion willIbewill
reviewed,
not userenewed,
any office
or resources
revised ontoa engage
periodicinbasis.
any kind of illegal act
ivities
q
Iorwill
to harass
reportanyone.
any violations of these rules to my supervisor or the Priv
acy Officer
named below. Any report I make will be held in confidence as per
mitted
q
byI will
law and
actIinwill
accordance
be free with
from these
any form
rules
of even
retaliation.
after I am no longer empl
qoyed in Ithis
agree
office.
to maintain all protected health information in a manner consist
qent withIflocal,
I havestate,
any questions
and federal
about
privacy
theseregulations.
rules and procedures or how and when
qthey apply
If IIviolate
will askthetheprivacy
privacyofofficer
any clients
or my PHI
supervisor.
or other confidential informa
tion I understand I will receive disciplinary action up to and including loss of
qmy job If
here.
I violate the privacy of any clients PHI or other confidential informa
qtion I understand
By signingIthis
may agreement,
be subject Itoagree
local,that
state,
I have
andread,
federal
havepenalties.
received a cop
y of, understand, and will comply with all the conditions outlined in this agree
__________________________
ment.
_______________________________
________
Printed name of employee
____
Signature of employee

_______________________________
Date
Printed
____________________________________
Name
of privacy
name of officer
practices representative________________________________
_______________________________________
Signature
Telephone number