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I understand that Woods & Water Medical Center in which or for whom I work, volunteer, receive
student training, provide services, or with whom the entity (e.g. physician practice) for which I
work has a relationship (contractual or otherwise) involving the exchange of health information
(Woods & Water Medical Center), has a legal and ethical responsibility to safeguard the privacy
of all patients and to protect the confidentiality of their patients health information. Additionally,
Woods & Water Medical Center must assure the confidentiality of its human resources, payroll,
fiscal, research, internal reporting, strategic planning, communications, computer systems, and
management information (collectively, with patient identifiable health information, Confidential
In the course of my employment/assignment/student training at Woods & Water Medical Center,
I understand that I may come into the possession of this type of confidential information. I will
access and use this information only when it is necessary to perform my job-related duties in
accordance with Woods & Water Medical Centers Privacy and Security Policies available on
Woods & Water Medical Centers information systems. I further understand that I must read, sign,
and comply with this Agreement in order to obtain authorization for access to Confidential

1. I will not disclose or discuss any 5. I will not access my own or my familys
confidential information with others, medical records in any information system
including friends or family, who do not have without prior authorization from the HIM
a need to know it. Manager unless required to perform my job
2. I will not discuss confidential information
where others can overhear the conversation. 6. I will not make any unauthorized
It is not acceptable to discuss confidential transmissions, inquiries, modifications, or
information even if the patients name is not purging of confidential information.
used. Furthermore, I will not download
confidential information off Woods & Water
3. I understand that I must safeguard and Medical Centers system, disc, zip discs,
maintain the confidentiality, integrity, and flash drives, or other portable media, etc.
availability of all confidential information I except in situations where explicit approval
use, disclose, and/or access at all times; to do so has been granted by the IT
whether or not I am at work, and regardless department with prior review by the Security
of how it was accessed. & Privacy officer. If I received this approval
to download data I will assume sole and
4. I will only access, use, and/or disclose the absolute responsibility to manage and
minimum necessary confidential protect it based upon standards listed in the
information needed to perform my assigned agreement and according to the law.
duties and disclose it to other
individuals/organizations who need it to 7. I will not in any way divulge, copy, release,
perform their assigned duties or as allowed sell, loan, alter, or destroy confidential
by law. information except as properly authorized.
8. I agree that my obligations under this 16. I will:
agreement will continue after my a. Use only my officially assigned User-ID and
termination of my employment, expiration password.
of my contract, or my relationship ceases b. Use only approved licensed software.
with Woods & Water Medical Center.
17. I will never:
9. Upon termination, I will immediately return a. Share/disclose User-Ids and passwords.
any documents or media containing b. Use tools or techniques to break/exploit
confidential information to Woods & Water security measures.
Medical Center. c. Connect to unauthorized networks through the
systems or devices.
10. I understand that I have no right to any
ownership interest in any information 18. I will notify my manager or IT if my password
accessed or created by me during my has been seen, disclosed, or otherwise
relationship with Woods & Water Medical compromised, and will report activity that
Center. violates this Agreement, privacy and security
policies, or any other incident that could have any
11. I will act in the best interest of Woods & adverse impact on Confidential Information.
Water Medical Center and in accordance
with its Code of Ethics at all times during 19. I have received training on how to protect health
my relationship with Woods & Water information/confidentiality as necessary and
Medical Center. appropriate to perform my job responsibilities.

12. I understand that violation of the agreement 20. I understand that I will be held accountable for all
may result in disciplinary action up to and inquiries, entries, and changes made to any of
including termination of employment, Woods & Water Medical Centers information
suspension, loss of privileges, and/or systems using my User name(s) and password(s).
termination of authorization to work within
Woods & Water Medical Center in
accordance with Woods & Water Medical
Centers policies.

13. I will only access or use systems or devices

that I am officially authorized to access, and
will not demonstrate the operation or
function of systems or devices to
unauthorized individuals.

14. I will practice good workstation security

measures such as: Locking up diskette
when not in use, using screen savers with
activated passwords appropriately, and
position screens away from public view.

15. I will practice secure electronic

communications by transmitting confidential
information only to authorized entities in
accordance with approved security
Refer any questions related to this agreement to the Security or Privacy Officer.

By signing this agreement, I agree to comply with its terms and conditions. Failure to read
this agreement is not an excuse for violating it. The IT department may deny access
to Woods & Water Medical Centers information systems if this agreement is not
returned signed and dated.

Employee Signature Date

Employee Printed Name

Return this completed from to Human Resources