Sample Medical Volunteer Confidentiality Agreement - Free Download
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2015 Volunteer Confidentiality Agreement Form #195(2/15)
HIPAA Privacy Protected Health Information (PHI) includes:
Patient name, address, DOB, social security number, all content of the medical record, medications etc.
Munson Policy adds additional disciplinary consequences for privacy violations involving mental health
records, substance abuse records, HIV status and other sensitive PHI.
Confidential Information is not to be shared inappropriately at work or away from work, via email, text, page,
written format, social media, photos, video, verbal disclosure, fax or other.
Examples of Privacy Breaches:
Announcing patient name or diagnosis loudly in a lobby area.
Verbal disclosure of lab results to others who are interested, but who have no job related need to know.
Visiting a patient on a restricted unit, such as Maternity, without their permission.
Visiting a co-worker who is hospitalized, without their permission.
Borrowing someone’s password to access records or lending someone your password.
Accessing a computer that is logged on under another’s password.
Disposing anything with a patient name on it in regular trash.
Mailing or giving Discharge Instructions or medications to the wrong patient.
Faxing PHI without FAX COVER SHEET and/or to the wrong Fax number.
Asking patients or visitors invasive questions such as “Why are you here” or “What surgery are you
having”
Accessing charts of ex -husbands or ex- girlfriends, etc, out of curiosity or concern, or to use in custody
battle.
Accessing chart to see why your co-worker is in the emergency department.
Disclosing patient presence in hospital after they had “opted out” of facility directory.
Leaving paper charts or census sheets open and unattended. Leaving PHI in hall, restroom or library.
Talking about your patients in a public place like the cafeteria or hair-dressers, or grocery store.
Talking about medical information in front of patient’s family without the patient’s permission.
Over Please - Please read and sign the back of this Confidentiality Form
