Basic Patient Confidentiality Agreement - Free Download
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Basic Patient Confidentiality Agreement
Basic Patient Confidentiality Agreement
Forward to: SFFD Compliance Officer, EMS Division, 698 Second St, SF, CA 94107
HIPAA Patient Confidentiality Agreement Form
All San Francisco Fire Department employees, volunteers, and outside workers, in all
ranks and in all assignments, have a legal and ethical responsibility to maintain the
privacy and confidentiality of patient health care information and to protect the privacy of
patients. Patient information, including, but not limited to, personal and medical
information, is confidential and privileged. You shall not discuss, disclose, share, and/or
release this information in any form, except as required for direct medical care of the
patient. You may view or use information as required for you to perform your job. You
may not view or use information for any other purposes.
Any and all electronic data systems that contain patients’ protected health information
(PHI), including patient information found in the Computer Aided Dispatch (CAD),
Incident Histories (QIH), dispatch run sheets (MDT), and personal information from
NFIRS and RMS fire incident reporting programs are also confidential. Only the
Medical Records Office of the SFFD EMS Division has the authorization to release these
Unauthorized disclosure of patient medical information is a federal crime. Any disclosure
of confidential patient health information without authorization may open the violator to
criminal liability and disciplinary action, up to and including termination.
By signing below, I agree to comply with all confidentiality policies and procedures set
in place by the San Francisco Fire Department.
_______________________________ ____________________________
Signature Date
Name (print) SFFD ID #
(SFFD Employees ONLY)
_______________________________ ____________________________
Job Title/Assignment Division/Unit
(Non-SFFD employees ONLY) (Non-SFFD employees ONLY)
Basic Patient Confidentiality Agreement Previous Page
Basic Patient Confidentiality Agreement