Last 4 Social Security #
Date of Birth
Work Phone Number
All employees of the ORGANIZATION must accept the terms of, and agree to be bound by, this Confidentiality of Information Agreement (“Agreement”) prior to being assigned duties or a computer access code or password authorization. No alterations to this Agreement are allowed.
As an employee of the ORGANIZATION, I understand that information to which I must have access in order to perform my duties may include CLIENT information or information regarding the operation of the ORGANIZATION. I am only permitted to access CLIENT medical information to the extent necessary for me to provide patient care or perform my duties. I also understand that all medical and personal information regarding patients is confidential and unless directly related to the care of patients and authorized by ORGANIZATION policy, should not be revealed or discussed with other patients, friends or relatives, or anyone else within or outside the ORGANIZATION environment.
I understand that I am required to protect any ORGANIZATION or operations information from loss, misuse, unauthorized access or modification, and to immediately report any suspected breach of security policies.
I understand that I may be given access codes or passwords to computer systems. I will safeguard the security codes and passwords given to me. I acknowledge that I am strictly prohibited from disclosing my security codes to anyone including my family, friends, fellow workers, supervisors, and subordinates for any reason. I agree ORGANIZATION data and ORGANIZATION reside and shall be stored ONLY on ORGANIZATION servers and NOT on any laptop, PCs nor any other device whether owned by ORGANIZATION or not.
I understand that failure to abide by the terms of this Confidentiality of Information Agreement is cause for termination of employment, revocation of privileges, or revocation of access to the ORGANIZATION, and may be noted in my personnel record.