Sign in to Google to save your progress. Learn more
Email *
Your name: *
Today's date: *
Hello from Dr. Slayton, your HIPAA Compliance Officer. All practice employees and others with access to sensitive patient information (ie-PHI and PII) are required to follow HIPAA and HITECH laws at all times. As required annually, please read the attached (see below) HIPAA training material. Thereafter, review and acknowledge the three sections of this HIPAA agreement. Lastly please electronically sign the HIPAA agreement and submit the form. Any questions or concerns should be directed to me. Thanks again! Dr. S
Please select the training type from below: *
Please read the below HIPAA training resource (click on link). Any questions or need for clarification should be directed to the Compliance Officer. *
HIPAA TRAINING RESOURCE: https://bit.ly/3e3o9lf
SECTION ONE: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule (Code of Federal Regulations, Title 45, Part 164) governs how Covered Entities, such as SHAWN SLAYTON, M.D. INC., may use and disclose Protected Health Information (PHI). This Confidentiality Agreement is intended to help protect PHI that may be included in documentation, communication or correspondence in any form, i.e. paper, magnetic or optical media, conversations, film, email, text messaging, etc. The intent is to assure that individually identifiable client information will remain confidential and its use will be limited to the minimum necessary to accomplish the health task being performed. I understand and acknowledge that, while performing my assigned duties for SHAWN SLAYTON, M.D. INC., I may have access to, use, or disclose PHI. I hereby agree to handle such information in a confidential manner and consistent with the limitations provided in HIPAA at all times during and after my employment or other access. *
SECTION TWO: I commit to the following obligations: A. I will comply with all federal and practice policies and procedures relating to the confidentiality of spoken, written or electronic PHI. B. I will use and disclose PHI only for the purpose of performing my assigned duties, in accordance with federal and practice policies. C. I will request, obtain, or communicate only the PHI necessary to perform my assigned duties and shall refrain from requesting, obtaining, or communicating more health information than is necessary. D. I understand that records accessed via any data source may contain sensitive and confidential information which should only be disclosed to those authorized to receive it. E. I will respect the confidentiality of any reports and handle, store, and dispose of these reports appropriately. F. I will take all reasonable care to properly secure PHI on my computer and will take steps to ensure that others cannot view or access such information. When I am away from my workstation I will lock my workstation in order to prevent access by unauthorized users. I will not leave a secured computer application unattended while signed on. G. I will not disclose my personal password(s) to anyone or post in an accessible location without express written permission and I will refrain from performing any tasks using another’s password. I further understand that I am responsible if another individual accesses confidential information using my password and I am responsible for all entries made and all retrievals accessed under my password, even if such action was made by me or by another due to my intentional or negligent act or omission. H. I understand that my use of an electronic information system may be periodically monitored to ensure compliance with this agreement. I. If I have reason to believe that the confidentiality of my user password has been compromised, I will immediately change my password and notify the Compliance Officer. J. The use of the SHAWN SLAYTON, M.D. INC. data network and internet connection is owned and controlled by the medical practice and my user privilege may be revoked at any time, for any reason, and my abuse or improper usage may be the basis for termination or corrective action. K. I understand that I have no right or ownership interest in any client or staff information. All records and charts are owned by the medical practice. L. I will immediately report any unauthorized use or disclosure of PHI that I become aware of to the Compliance Officer. M. I will refer public records requests to the Compliance Officer. N. I agree that disclosure of confidential information is prohibited even after termination of employment or business relationship, unless specifically waived in writing by the authorizing party. The confidentiality requirements of this agreement shall survive its termination, expiration or cancellation. *
SECTION THREE: I acknowledge that I have been trained in the requirements of the privacy provisions of HIPAA and the breach provisions of HITECH. I understand that the HIPAA law itself provides for criminal penalties for its violation and I also understand and agree that my failure to fulfill any of the obligations set forth in this agreement and/or my violation of any terms of this agreement shall result in my being subject to appropriate disciplinary actions as described by law. *
I understand that typing my name below and submitting this form is considered an electronic signature; whereby I agree and stipulate to the provisions of this agreement and annual training as outlined above. *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Shawn Slayton, M.D. Inc.. Report Abuse