HIPAA Confidentiality Form
Please read this form carefully and sign to confirm your agreement.
Acknowledgement and Agreement
Confidentiality Obligations: I may have access to confidential PHI as part of my role.
Use and Disclosure of PHI: I will only use or disclose PHI as permitted by law, my job responsibilities, and company policies.
Safeguarding Information: I will take all reasonable steps to protect PHI from unauthorized access, use, or disclosure.
Reporting Breaches: I will immediately report any known or suspected breach of PHI to the designated compliance officer or supervisor.
Consequences of Non-Compliance: I understand that violations of HIPAA regulations or this agreement may result in disciplinary action, termination, and potential legal consequences.
By signing below, I confirm that I have read, understand, and agree to comply with the terms of this confidentiality agreement.
Name:
Date:
Form Templates @ Template.net
![]()
Thank you for your submission!
We appreciate you taking the time to submit.
Create free forms at
