HIPPA Compliance Form

    I am/or will be an employee, volunteer or other member of the Workforce of Hamilton Medical Center (ex: Job Shadow Program), and I acknowledge that I have completed training on the Hospital’s privacy policies and the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (also known as the HIPAA Privacy Rule).

    • I have watched the HIPAA video in it's entirety.
    • I understand that all patient information, including billing and financial data, is confidential.
    • I agree to keep patient information confidential.
    • I agree to comply with all Hospital Privacy Policies and Procedures including those implementing the HIPAA Privacy Rule.
    • I understand that if I violate patient confidentiality by using or disclosing patient information improperly, I may be subjected to disciplinary action up to and including termination of my employment.
    • I understand that if I have any questions or concerns about the Privacy Rule and/or the proper use or disclosure of patient information, I should ask my Supervisor, the Hospital Privacy Officer or the Hospital Compliance Officer.
    • I understand and agree that the Hospital Privacy Policies and Procedures will apply to any patient information I have access to at the Hospital even after I terminate my employment or other relationship with the Hospital.
     By checking this box and submitting this form, I verify that the above information is correct
    and accurate to the best of my knowledge. I also understand and agree with the content/stipulations listed above.