Organization Or Privacy Officer Name

Organization or Privacy Officer Name

Site Address

City, State, Zip

Phone

Fax

Confidentiality and Non-Disclosure
for Visitors & Non-Workforce Members

This form comprises a strict confidentiality and non-disclosure agreement between Organization Name, and a non-workforce member who will be on-site observing operational activities. The purpose of this form is to bind visitors (i.e., students touring the facility, trainees from other Organization sites, vendors, et al.) so that they do not disclose patient data that they are incidentally exposed to during their visit. This form should be signed by the visitor and by the Organization Name workforce member who is responsible for the visitor.

I certifythat I am visitingOrganization Name for training, observation and/or educational purposes FROM (Date) _____/_____/______TO (Date) _____/_____/______

I understand that while I am visiting in this capacity, I may be exposed to confidential information which includes protected health information (PHI), other sensitive or proprietary Organization information that is protected by federal HIPAA privacy regulations, other laws or Organization Name policies.

I agree to adhere to the following guidelines:

Use of any protected health information (PHI) or other confidential information is only for the training, observational and/or educational purpose(s) of my visit and I will keep the information confidential.
All patient information (including patients’ personal, financial, and health information) as well as information regarding ‘Organization’ operations, employees/human resources is confidential. Any inappropriate viewing, discussion, or disclosure of this information is a violation of policy.
This information is privileged and confidential regardless of format: electronic, written, overheard or observed verbal communication.
Visitors must not attempt to view, hear, copy, or otherwise access any PHI. Any inappropriate viewing, discussion, or disclosure of PHI is a violation of policy and may be a violation of HIPAA and other state/federal laws. Any such violation(s) may lead to civil liability and/or criminal charges.
Notes must not be taken if information includes any PHI.
Visitors must not attempt to access any PHI or confidential information about themselves, their family, or any other person.
If a visitor accidentally sees, hears, or is otherwise exposed to patient information, he/she must not disclose the patient information to anyone. This includes telling another person about patients that were present within our Organization.
Photographing our facilities, employees, or patients is prohibited. This includes taking pictures or videos with digital recording devices and/or cell phone cameras.
Visitor confidentiality obligations continue after the visit to this organization ends.

I understand that I may direct any questions I have about my obligations under this Confidentiality Pledge or under any of the policies and applicable laws and regulations related to confidentiality to this organization’s Privacy Official.

Signature Page Follows on Reverse

______

NAME of Visitor

______

SIGNATURE of Visitor DATE

______

VISITOR’S ADDRESS or ORGANIZATION AFFILIATION

I, as Organization sponsor of the above-named visitor, have reviewed this pledge of confidentiality with the visitor and certify that the visitor is here for training, observational and/or educational purposes.

______

NAME of Responsible Party

______

SIGNATURE of Responsible Party DATE

NOTE: This form is to be forwarded to the Privacy Officer for storage and documentation for the minimum HIPAA-defined timeframe.

Reference, to be remove before form customization or printing

• PRA Line Items: D.8, J.2