Human Resources Confidentiality Agreement Template - Free Download
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Please complete and mail, scan/email, or fax back to Attn: Volunteer Intern, Community Affairs &
Engagement/Volunteer Services, Regional Medical Center at Memphis, 877 Jefferson Ave.,
email@example.com, Office: 901.545-7427, Fax: 901.545.8604.
Regional Medical Center at Memphis (The MED) has a legal and ethical responsibility to safeguard the
privacy of all patients and to protect the confidentiality of their health information. Additionally, the
organization must assure the confidentiality of its human resources, payroll, financial, research,
computer systems, and management information. I understand that, in the course of my
employment/assignment at Regional Medical Center, I may come into possession of confidential
information, even though I may not be directly involved in providing patient services. Such information
may be in any form, including paper records, oral communications, audio recordings, and electronic
displays. In addition, the personal access code(s) [USER ID(s) and PASSWORD(s)] I use to access
computer systems are also an integral part of this confidential information.
By signing this document I understand the following:
I agree not to disclose or discuss any patient, human resources, payroll, financial, research and/or
management information with others, including friends or family, who do not have a need-to-know.
I agree not to access any information, or utilize equipment, other than what is required to do my
job, even if I don’t tell anyone else.
I agree not to discuss patient, human resources, payroll, financial, research or management
information where others can overhear the conversation, e.g. in hallways, on elevators, in the
cafeteria, on public transportation, at restaurants, or at social events.
I agree not to make inquiries for other persons who do not have proper authority.
I agree not to willingly inform another person of my computer password or knowingly use another
person’s computer password instead of my own for any reason.
I agree not to make any unauthorized transmissions, inquiries, modifications, or purging of data in
any system. Unauthorized transmissions include, but are not limited to, removing and/or
transferring data from Regional Medical Center at Memphis’ computer systems to unauthorized
locations or systems, e.g. home.
I agree to log off prior to leaving any computer or terminal unattended.
I agree that I have a duty to report any breach of confidentiality that I may observe or become
I understand that violation of this agreement may result in corrective action, up to and including
termination of employment and/or suspension and loss of Regional Medical Center privileges in
accordance with applicable Regional Medical Center policies. Unauthorized release of confidential
information may also result in personal, civil, and/or criminal liabilities and legal penalties.
I have read and agree to comply with the terms of the above statement, and will read and comply with
Regional Medical Center’s Corporate Privacy and Information Security Policies and Standards.
Name: _________________________ Employee #: ___________ Department: ___________________
Signature: _______________________________________ Date: _____ /______/_________
Relationship with Hospital:
( ) Resident
( ) SCHCC Employee
( ) Volunteer
( ) Medical Staff Physician
( ) Student of __________________School
( ) Referring Physician
( ) Other _____________________________