HIPAA Confidentiality Agreement Form
Please fill out the form below to complete the agreement.
Employer
Employee
Recipient's Obligations
Confidentiality: The Recipient agrees to maintain the confidentiality of all PHI obtained during the course of their duties.
Permitted Use: PHI will only be used or disclosed as necessary to perform assigned duties, in accordance with HIPAA regulations.
Safeguards: The Recipient will implement appropriate safeguards to prevent unauthorized use or disclosure of PHI.
Reporting: Any unauthorized access, use, or disclosure of PHI must be reported immediately to the Covered Entity.
Return or Destruction of PHI: Upon termination of the agreement or duties, the Recipient agrees to return or securely destroy all PHI in their possession.
Prohibited Actions
The Recipient agrees not to:
Acknowledgment and Agreement
By signing this Agreement, the Recipient acknowledges understanding their responsibilities under HIPAA and agrees to comply fully with its requirements.
Recipient
Name: Date: | Employer
Name: Date: |
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