Uw Medicine Vendor Confidentiality Agreement Sample Template - Free Download
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Uw Medicine Vendor Confidentiality Agreement Sample Template
Uw Medicine Vendor Confidentiality Agreement Sample Template
Rev. 3/8/2007
UW Medicine
VENDOR CONFIDENTIALITY AGREEMENT
A. VENDOR INFORMATION (to be completed by Vendor representative)
Name (“Vendor”)
Company
Address
City, State, ZIP
Phone number
Fax:
Email
Select applicable box:
1. I will be visiting clinical areas to
provide equipment or product or information for a clinical area.
2. I will be visiting clinical areas and need to use and/or disclose Protected Health Information (PHI)
of UW Medicine patients. I confirm that a Business Associate Privacy Agreement (“Agreement”)
has been signed between my Company and a UW Medicine Entity and I shall only use and/or
disclose PHI only as provided for within that agreement.
3. I will be visiting clinical areas but will not need to use and/or disclose PHI of UW Medicine patients.
Any encounter with PHI will be incidental.
B. Vendor Confidentiality Acknowledgement
UW Medicine has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their
protected health information (PHI). Strong federal and state laws govern the privacy of our patients and their health information.
When visiting clinical areas at UW Medicine, Vendor will or may see patients with a variety of medical issues and/or Vendor may see
and hear confidential information relating to these patients. This information relates to past, present and future health care.
As a condition of accessing UW Medicine premises, Vendor understands and agrees that:
Vendor must maintain and safeguard the confidentiality of any and all UW Medicine protected health information.
Vendor shall not access, use or disclose protected health information, for any purpose other than treatment, unless a Business
Associate Privacy Agreement has been signed between the Vendor’s Company and a UW Medicine Entity or as otherwise
permitted by federal and Washington State law. Vendor will maintain all protected health information in the strictest confidence
and will not disclose or allow access to protected health information to others.
Any authorized access to protected health information may be monitored to assure appropriate compliance with system
integrity and UW Medicine policies and procedures.
Failure to comply with the above confidentiality guidelines, or in the event of a breach of patient confidentiality, this agreement
and any existing agreements may be terminated and Vendor’s ability to participate in future activities at UW Medicine may be
denied.
Signature of Vendor Representative (“Vendor”) Date
C. Agreement to be retained by UW Medicine Department:
I understand that I will be responsible for this Vendor when they are accessing clinical areas. If the Vendor must use PHI for
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