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
I understand that all patient information,
including billing and financial data, is confidential.
I agree to keep patient information
I agree to comply with all Hospital Privacy
Policies and Procedures including those implementing the HIPAA
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.