Download Personal Confidentiality Agreement For Physician for Free

(4.3 based on 553 votes)
Please see warning and disclaimer on page 2 of the whole BC Physician Privacy Toolkit 1
Last updated on June 15
, 2009
Confidentiality Agreement for Physician Office Employees
The BC Personal Information Protection Act (PIPA) legally governs personal information collected, used,
stored, and disclosed by this medical practice. As such, you are required to acknowledge each term of
this agreement:
I am aware that personal information of both patients and employees that is collected, used, stored,
and disclosed, that comes to my attention as a result of my employment with this medical practice,
must be kept confidential and secure as per PIPA and the office’s policies, both during and after my
term of employment.
I understand and agree that it is my responsibility to be familiar with the practice’s policies and
procedures regarding privacy, confidentiality and security of personal information and that I am
expected to comply.
I will access and use personal information of patients only on a “need to know” basis as it pertains to
my role and responsibilities.
I will only share personal information with individuals who need to know and who are also involved in
providing health care services to the patient.
I will strive to keep patient personal information accurate and up-to-date.
I understand that I cannot access my own personal information or that of family, friends, or co-
workers unless they are under my direct care or if I need to do so as part of my official duties and
responsibilities with the practice.
Should I have reason to believe that a privacy breach has occurred, I will notify the individual
responsible for privacy in the office.
I hereby acknowledge that failure to comply with these terms can lead to disciplinary action, which
may include termination of access, termination of employment, withdrawal of privileges, termination of
contract, and/or professional sanctions.
Employee Print Name: ____________________________
Signature: ____________________________
Date (dd/mm/yyyy): ______________________
Medical Practice or Physician Print Name: ____________________________
Privacy Officer Witness Print Name: ____________________________
Signature: ____________________________
Date (dd/mm/yyyy): ______________________
Personal Confidentiality Agreement For Physician
1 / 1 >