Medical Procedure Confidentiality Agreement Example - Free Download
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NON-EMPLOYEE CONFIDENTIALITY AGREEMENT
As a non-employee of Advocate Health Care, you or your representatives may have access to patient, medical record, employee or
other confidential information. As a condition to being granted such access, you are required to agree to the following:
I understand that in the course of my working relationship with Advocate Health Care, I share the responsibility of maintaining the
confidentiality of any patient, medical record or employee information that I may have available to me. I understand that it is my
responsibility to follow Advocate Health Care policies and procedures as they relate to the assurance of patient rights and the
confidentiality of information both written and verbal.
Computer Systems:
I understand that I may receive a unique User-Id and a personal password necessary for me to gain access to an Advocate Health
Care computerized system. I understand and agree that both the User-id and my Password are for my own personal use and are not
to be disclosed to or used by third parties. If at any time I feel that the confidentiality of my User-id or password has been
compromised, I will contact appropriate management (Advocate employee that approved your access) for direction within 24 hours.
Conduct and Confidentiality:
I understand that I must maintain the confidentiality of any written or oral patient, medical record or employee information that I
have access to or view as a result of my working relationship with Advocate Health Care. I understand that the release of patient,
medical record or employee information of any kind is only allowed by Advocate Health Care policy guidelines. If I am uncertain or
do not understand the Advocate Health Care policy guidelines, I will contact the appropriate Advocate manager (Advocate employee
that approved your access) for assistance and direction within 24 hours. I agree to only release patient, medical record or employee
information under the Advocate Health Care policy guidelines or as required by law.
Patient, Medical Records and Employee Information:
I acknowledge that all information involving patients, medical records and employee information is private and confidential. I agree
that I shall access only that data necessary for the proper performance of my job responsibilities under my business relationship with
Advocate Health Care. I further agree to keep confidential any and all information that I access, receive or transcribe, and not to
disclose any such information to third parties. I am aware, that, unless specifically identified as part of my job by “Advocate Health
Care”, I am not authorized to discuss any information concerning a patient or employee’s personal data or medical condition. I am
responsible for ensuring that discussions regarding patient, medical record and employee information are held in appropriate
locations with only authorized individuals.
Any unauthorized disclosure on my part or my representatives will be a very serious offense to Advocate Health Care. Such
unauthorized disclosure may result in Advocate’s repossession of all of my or my representative’s access to patient, medical record
and employee information, Advocate may also act up to and including termination of my business relationship with Advocate and
asserting its full rights under the law.
_____________________________________ __________________________________________________
School Name Signature Date
_____________________________________ __________________________________________________
Witness Signature Date
SS# _____________________ Dept ______________ Start Date: _________ End Date: ___________
Printed Name
