Pediatric Healthcare Connection - Hipaa Agreement

Employee Acceptance of HIPAA Privacy Rules and Regulations

(Health Insurance Portability and Accountability Act of 1996)


I understand that while performing my jobs duties for Pediatric Healthcare Connection (PHC) at my workplace, I may have access to protected health information (PHI) about patients or residents of hospital or nursing homes and rehabilitation centers (hospital).

PHI means any information specifically relating to the past, present or future physical or mental health condition of an individual, the provision of healthcare to an individual or payment for healthcare to an individual, and is limited to information created or received by me from the hospital.

To insure confidentiality and privacy of PHI, I agree to:

  • Access, use or review PHI only as needed for the purpose of performing the job for which I was officially employed.
  • Never use PHI out of curiosity, or for personal interest or advantage, or in the presence of an unauthorized third party.
  • Never take with me any photocopies of documents from any patient or resident medical or personnel file when I end my daily shift or employments.
  • Report to the designated primary officer or my workplace, and to Pediatric Healthcare Connection, any use or disclosure of PHI by anyone else that is not permitted of which I may become aware within 24 hours of my discovery of such unauthorized use or disclosure.


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