PATIENT/CLIENT CONFIDENTIALITY HIPPA REGULATIONS

Please be reminded of the following information:

Patient confidentiality

It is the policy of Grace and Mercy Health Services that all employees, contractors and volunteers of Grace and Mercy Health Services will maintain and uphold confidentiality of patient information at all times.

According to Healthcare regulation it is the policy of GMHS to provide our employees with patient information about a client at the time when an employee is assigned a case.

I, (Please input name below) hereby agree to keep all personal and medical information of Grace and Mercy Health Services, and/or her patients/clients, confidential.. Furthermore, I agree not to releaser any information to any outside organization or agency without the approval of the agency patient/client, or as required by law or third party payment contract.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.