Example Standard Patient Confidentiality Agreement - Free Download
4.6, 3330 votes
Please vote for this template if it helps you.
It is the responsibility of all UC San Diego Health System (UCSDHS) workforce members, as defined above,
including employees, medical staff, house staff, students and volunteers, to preserve and protect confidential
patient, employee and business information.
The Federal Health Insurance Portability Accountability Act (HIPAA) Privacy Law, the Confidentiality of Medical
Information Act (California Civil Code § 56 et seq.) and the Lanterman-Petris-Short Act (California Welfare &
Institutions Code § 5000 et seq.) govern the release of patient identifiable information by hospitals and other
health care providers. The State Information Practices Act (California Civil Code sections 1798
et seq.) governs the acquisition and use of data that pertains to individuals. All of these laws establish
protections to preserve the confidentiality of various medical and personal information and specify that such
information may not be disclosed except as authorized by law or the patient or individual.
Confidential Patient Care Information includes: Any individually identifiable information in possession or
derived from a provider of health care regarding a patient’s medical history, mental, or physical condition or
treatment, as well as the patients and/or their family members records, test results, conversations, research
records and financial information. Examples include, but are not limited to:
• Physical medical and psychiatric records including electronic, paper, photo, video, diagnostic
and therapeutic reports, laboratory and pathology samples;
• Patient insurance and billing records;
• Mainframe and department based computerized patient data and alphanumeric radio
• Visual observation of patients receiving medical care or accessing services; and
• Verbal information provided by or about a patient.
Confidential Employee and Business Information includes, but is not limited to, the following:
• Employee home telephone number and address;
• Spouse or other relative names;
• Social Security number or income tax withholding records;
• Information related to evaluation of performance;
Peer review and risk management activities and information are protected under California
Evidence Code section 1157 and the attorney-client privilege.
• Other such information obtained from the University’s records which if disclosed, would
constitute an unwarranted invasion of privacy; or
• Disclosure of Confidential business information that would cause harm to UCSDHS.
D214 (8-13) FRONT
Applies to all UC San Diego Health System (UCSDHS) “workforce members” including: employees, medical staff and other
health care professionals; volunteers; agency, temporary and registry personnel; and house staff, students, and interns
(regardless of whether they are UCSD trainees or rotating through UCSDHS facilities from another institution).