Kadlec Medical Center
Joint Notice Agreement
In consideration of, and as a requirement of, my on-going ability to provide services at or through Kadlec Medical Center (“KMC”), I agree as follows:
1.Organized Health Care Arrangement. I recognize and acknowledge that KMC, I, and those Medical Staff members who provide professional services at or through KMC pursuant to a service agreement for services provided at or through KMC participate in an organized health care arrangement that uses, and relies upon, a joint Notice of Privacy Practices and acknowledgment (the “OHCA”). This OHCA is recognized solely to facilitate compliance with the Health Insurance Portability and Accountability Act of 1996.
2.Notice of Privacy Practices. I agree to abide fully by the provisions of the joint Notice of Privacy Practices implemented by KMC, as may be revised from time to time, with respect to patient health information created or received as part of my participation in the OHCA for services provided at or through KMC and to comply fully with the underlying KMC policies and procedures.
3.Confidentiality. I will maintain the privacy, security, integrity, and confidentiality of all KMC patient health information, in any form or medium (e.g., verbal, written, or electronic). I will access such patient health information only when I have a need to know to perform my job responsibilities. If, on behalf of KMC, I receive authorization to use or disclose a “limited data set,” which is patient information that has had some but not all identifiers removed, then I specifically agree to only use or disclose the limited data set for the authorized purpose, which must be research, public health, or health care operations and to comply with KMC’s policies and procedures.
4.Independent Responsibilities. I recognize I am responsible for my own compliance, and I will comply, with applicable federal and state laws relating to patient health information. I will not act or fail to act in a manner that, directly or indirectly, would cause KMC to not be in compliance with applicable law. The recognition of the OHCA shall not be construed: to shift responsibilities or liabilities between or among OHCA members; to cause one or more OHCA members to assume responsibility for the actions or failures to act of any other OHCA member; or to create or constitute an agency or other similar arrangement between KMC and me or between KMC and any organization that employs or contracts with me. Violation of this Agreement may constitute grounds for corrective action, up to and including being prohibited from practicing at KMC.
I have voluntarily executed this Agreement on the date indicated below:
Signature:
Print Name:
Date:
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SEA 1341151v1 21101-11