Policy Manual sample

MDT Home Health Care Agency, Inc. PERSONAL HEALTH INFORMATION PLEDGE OF CONFIDENTIALITY Employee Name: _____________________________ I, the undersigned, have read and understand theMDT Home Health Care Agency, Inc. (hereinafter "MDT Home Health Care Agency, Inc.") policy on confidentiality of personal health information (PHI) as described in the Confidentiality Policy which is in accordance with relevant state and federal legislation. I also acknowledge that I am aware of and understand the Policies of the MDT Home Health Care Agency, Inc. regarding the security of personal health information including the policies relating to the use, collection, disclosure, storage and destruction of personal health information. In consideration of my employment or association with MDT Home Health Care Agency, Inc., and as an integral part of the terms and conditions of my employment or association, I hereby agree, pledge and undertake that I will not at any time, during my employment or association with MDT Home Health Care Agency, Inc., or after my employment or association ends, access or use personal health information, or reveal or disclose to any persons within or outside MDT Home Health Care Agency, Inc., any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable Legislation, and MDT Home Health Care Agency, Inc. policies governing proper release of information. I understand that my obligations outlined above will continue after my employment/contract/association/ appointment with MDT Home Health Care Agency, Inc. ends. I further understand that my obligations concerning the protection of the confidentiality of PHI relate to all personal health information whether I acquired the information throughmy employment or contract or association or appointment with MDT Home Health Care Agency, Inc. or with any of the entities, which have an association with MDT Home Health Care Agency, Inc. If for any reason I must complete any clinical documentation of any of my patient at later time, or at my residence, I assure that no Protected Health Information will be left unattended in my vehicle. In my residence, it will be placed in a secure location where children or any family member will not have access to it at any time. All family members will be alerted about the Confidentiality status of such records. I also understand that unauthorized use or disclosure of such information will result in a disciplinary action up to and including termination of employment or contract or association or appointment, the imposition of fines pursuant to relevant state and federal legislation, and a report to my professional regulatory body. _______________________________________ _________________________ SIGNATURE OF INDIVIDUAL MAKING PLEDGE Date I have been informed of the contents of MDT Home Health Care Agency, Inc.’s Personal Health Information Confidentiality Policy and the consequences of a breach. _______________________________________ ________________________ SIGNATURE OF INDIVIDUAL ADMINISTERING PLEDGE Date I have discussed the Personal Health Information Confidential Policy and the consequences of a breach with the above named. Note: The Pledge of Confidentiality must be taken at Employee/Contractor Application Process. The Human Resources, Personnel Department, or Administrator are responsible for the compliance of this standard. Home Health Agency Policies A-90