Sample Ethics Contract
for Employees, Trainees, and Volunteers
in Mental Health Settings
(Includes Confidentiality Contract)

LETTERHEAD

I understand that certain ethical standards must be maintained in this setting and I have received training about those standards, in the form of an ethics manual, individual training, or group training. I further understand that failure to maintain those standards will be considered grounds for disciplinary action, up to and including my immediate dismissal.

I am aware of the special importance of the confidentiality standards described in professional Ethics Codes, state laws and federal HIPAA regulations. I have read the Confidentiality Statement below and agree to abide by it.

CONFIDENTIALITY STATEMENT:
All patient information is to be treated as confidential, including the fact that the patient receives (or previously received) services through this office. The privacy and confidentiality of our patients are protected under the Ethics Codes of the mental health professions, the laws and regulations of the Commonwealth of Virginia, and Federal HIPAA Regulations. No patient information may be disclosed without the explicit informed consent of the patient and authorization by his/her clinician.

The following types of disclosures are inappropriate, unethical, and/or illegal:

== Discussing/revealing patient information to anyone outside this office (e.g., friends, family, fellow students or supervisees, etc.).
== Removing any patient information from this office for any purpose (including working from home) without explicit authorization from the patient's clinician in each case.
== Discussing/revealing patient information to another employee who has no legitimate need to know.
== Obtaining access to patient information not directly necessary for performing your job duties.
== Copying patient files or other patient information onto your own computer
==Sending any patient information via e-mail or FAX without explicit authorization from the clinician.
== Copying patient files or other patient information onto CD, floppy disk, or other electronic medium, without explicit authorization from the patient's clinician for a specific purpose, except when conducting authorized computer backup on a scheduled basis.
== Placing patient information onto the internet or into any other publicly-available forum.

EMPLOYEE CONFIDENTIALITY AGREEMENT
I hereby acknowledge, by my signature below, that I understand that any patient information to which I have access is considered confidential, including clinical records, financial records, or any other identifiable information about a patient. I understand that confidentiality must be maintained whether the information is stored on paper or on computer, or was communicated orally or through any other means.

I understand that I am authorized to have access only to certain information, and I understand that information not necessary for fulfilling my specific job description should not be read or discussed. I also understand that employee information of a private or sensitive nature must also be treated as confidential, including employment records, job evaluations, etc. I have been informed that it is illegal for me to access computerized patient or employee information without authorization of my supervisor.

I understand the non-disclosure guidelines of this office. I know that patients have received a "Notice of Privacy Practices" which describes the confidentiality and non-disclosure guidelines, and that these authorize me to have access to certain patient information in the performance of my routine duties. I understand that further authorization would be needed for me to disclose that information to anyone for any other purpose. I agree to disclose no patient information without being explicitly notified by a clinician or supervisor that the patient has given informed consent for it to be so disclosed.

I understand that unauthorized disclosure of patient information, or any other confidential or proprietary information from this office, is unethical and/or illegal, and that it is grounds for disciplinary action, up to and including my immediate dismissal. I understand that this duty of confidentiality and non-disclosure will continue to apply even after I am no longer working in this office

Employee Name (Print)_________________________________________
Employee Signature ________________________________ Date: ______
Witness Signature__________________________________ Date: ______

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