Form 1: Confidentiality Agreement
Maria S DSouza MS MD
Employee of: Maria S DSouza MS MD
1. I am aware that within this medical practice, I will have access to confidential information regarding patients, and I will not disclose any information outside of the practice, except as permitted by the practice.
2. I will only use systems secure for PHI (protected health information) to message or talk to the patient, or people designated in writing by the patient.
3. I will keep all patient information private regarding any patient seen or spoken with at the practice.
4. PRIVATE information includes, but is not limited to:
- Medical documents, demographics, insurance, and billing
- Medical information and other personal information about employees.
- Medical records and proceedings regarding anyone working at the practice or patient of the practice.
- Reports, policies, and procedures, marketing, financial information
- Salary, bonuses, and other remuneration items
5. Medical information is confidential and my access is restricted to my legitimate medical need to know for diagnosis, treatment, and care of a particular patient.
6. All documents pertaining to any patient or the practice are to remain at the office at all times, unless permitted in writing by Dr. Maria D'Souza
7. My access of PHI (protected health information) and other sources of information is subject to routine, random, and undisclosed surveillance by Dr. Maria D'Souza
8. Failure to comply with confidentiality obligation may result in discipline action or termination. Impermissible disclosure of confidential information about a person may result in legal action.
9. If I am given a unique set of codes or passwords, it is my responsibility to keep this information private without sharing codes and or passwords with others.
10. I will not discuss any medical issues or conditions regarding a patient in public such as waiting areas, hallways, elevators, outdoors, other businesses, or places of abode where people not specified by the patient can see or hear me.
Employee Signature
By signing below, you confirm you have read and agree to the terms of this Confidentiality Agreement.