Confidentiality Agreement

The Federal Health Insurance Portability Accountability Act (the “Privacy Rule”), govern the release of patient identifiable information by home health agencies and other health care providers. These laws establish protections to preserve the confidentiality of various medical and personal information and specify that such information may not be disclosed except as authorized by law or the patient or individual.

Confidential Patient Care Information includes: Any individually identifiable information in possession or derived from a provider of health care regarding a patient's medical history, mental, or physical condition or treatment, as well as the patients and/or their family members records, test results, conversations, research records and financial information. (Note: this information is defined in the Privacy Rule as “protected health information.”) Examples include, but are not limited to:

•Physical medical and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples;

•Patient insurance and billing records;

•Computer and department based computerized patient data; and

•Visual observation of patients receiving medical care or accessing services; and

•Verbal information provided by or about a patient

Confidential Employee and Business Information includes, but is not limited to, the following:

•Employee home telephone number and address:

•Spouse or other relative names;

•Social Security number or income tax withholding records;

•Information related to evaluation of performance;

•Other such information obtained from the Agency records which if disclosed, would constitute unwarranted invasion of privacy; or

•Disclosure of Confidential business information that would cause harm to the AGENCY. I understand and acknowledge that:

1. I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in connection with individual patient care, risk management and/or peer review activities.

2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and other confidential information relating to the AGENCY and its affiliates, including business, employment and medical information relating to our patients, members, employees and health care providers.

3. I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of the AGENCY, or where no officially adopted policy exists, only with the express approval of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the conduct of the AGENCY affairs.

4. The AGENCY Administration performs audits and reviews patient records in order to identify inappropriate access.

5. My user ID is recorded when I access electronic records and that I am the only one authorized to use my user ID. I will only access the minimum necessary information to satisfy my job role or the need of the request.

6. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information.

7. I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a component of HIV, or antibodies or antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me subject to legal and/or disciplinary action.

8. My obligation to safeguard patient confidentiality continues after my termination of employment with the AGENCY.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that the AGENCY may, as applicable and as it deems appropriate, pursue disciplinary action up to and including my termination from the AGENCY.

I understand that the above mentioned materials provide guidelines and summary information about the company’s policies and procedures. I also understand that it is my responsibility to read, understand, become familiar with, and comply with the standards that have been established.

By affixing my signature hereunder, I authorize Agency to release any and all confidential employment background check and medical information contained in my employment file to any medical facility or entity with which Agency has staffing agreement, and to any other governmental or regulatory agency such agency’s request. For all other purposes, Agency Staffing, Inc, shall keep my employment confidential and shall advise any medical facility or other entity to which records have been provided to also keep such record confidential. I hereby hold Agency harmless for any result (s) that arises with regards to the release of this confidential information by Agency Medical records information is confidential and Agency will instruct client facilities and / or other entities to treat the provided information confidential as well.

I consent to a urine, blood or breath sample for the purpose of an alcohol drug, intoxicant or substance abuse screening test. Furthermore, I consent to the release of the results for purposes for determining the fitness of employment or continued employment.

I authorize Agency to contact past employers and references regarding my employment history. I hereby release all previous employers and references from any liability for furnishing this information in this application, reference information and medical information to Agency and any facilities I might be sent on assignment.

My signature hereunder further indicated that I have read and understood the Employee authorization to release confidential information on employment file, background check, medical records and drug screening.

I certify that the facts contained in this application are true and accurate. I authorize the employer to investigate any and all questions relating to this application. I release all parties from all liability, including but not limited to, the employer and any person, firm or corporation who provides information concerning my prior education, employment or character.

Agency does not discriminate in respect to hiring, termination, compensations and all other terms and conditions of privileges of employment on the basis of race, color, national origin, ancestry, sex, age, pregnancy or related medical conditions, marital status, religious creed or disability.