Example Medical Research Confidentiality Agreement - Free Download | Page 2
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I understand and acknowledge that:
1. I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and
any other information generated in connection with individual patient care, risk management and/ or
peer review activities.
2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical
records, proprietary information and other confidential information relating to UCSDHS and its affiliates,
including business, employment and medical information relating to our patients, members, employees
and health care providers.
3. I shall only access or disseminate patient care information in the performance of my assigned duties and
where required by or permitted by law, and in a manner which is consistent with officially adopted policies
of UC San Diego Health System, or where no officially adopted policy exists, only with the express approval
of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient
care records or any other patient care, peer review or risk management information, except to persons
authorized to receive it in the conduct of UC San Diego Health System affairs.
4. UCSDHS performs audits and reviews patient records in order to identify inappropriate access.
5. My user ID is recorded when I access electronic records and that I am the only one authorized to use my
user ID. Use of my user ID is my responsibility whether by me or anyone else. I will only access the
minimum necessary information to satisfy my job role or the need of the request.
6. I agree to discuss confidential information only in the work place and only for job related purposes and
to not discuss such information outside of the work place or within hearing of other people who do not
have a need to know about the information.
7. I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to
identify HIV, a component of HIV, or antibodies or antigens to HIV, are specifically protected under law
and unauthorized release of confidential information may make me subject to legal and/or disciplinary
action.
8. I understand that the law specially protects psychiatric and drug abuse records, and that unauthorized
release of such information may make me subject to legal and/or disciplinary action.
9. My obligation to safeguard patient confidentiality continues after I am no longer a UCSDHS
workforce member.
I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies
my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality
Agreement, I acknowledge that the University of California may, as applicable and as it deems appropriate, pursue
disciplinary action up to and including termination from my employment or affiliation with the University of California.
Print Name:
Signature:
Department:
Dated:
D214 (8-13) BACK
