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Sample
Confidentiality Contract
for
Employees & Other Non-Clinical Staff
in Virginia Mental Health Settings
(Also
for Students, Supervisees, & Volunteers in your "Workforce")
LETTERHEAD 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: ______ HOME
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