Confidentiality Agreement for Non-Employees and Volunteers

This agreement is entered into between you and Ballad Health (formerly Mountain States Health Alliance (MSHA))

 

Ballad Health has a long tradition of protecting the privacy of patient information, including patient names, addresses, telephone numbers, social security numbers, diagnoses, pharmacologic and surgical interventions as well as the testing and results associated with the delivery of care to a patient at any Ballad Health facility. 

Our commitment to patient confidentiality is reinforced by the privacy and security regulations created as part of the Health Insurance Portability and Accountability Act (“HIPAA”). These regulations require Ballad Health and those who are exposed to protected health information to keep patient information confidential. Ballad Health is committed to ensuring the privacy of patient information and complying with any state and/or federal regulations to protect patient information. 

By signing this agreement, I understand that maintaining the confidentiality of patient information is a condition of my continued relationship with Ballad Health. Therefore, I agree to maintain the confidentiality of all patient information, including patient names, addresses, telephone numbers, social security numbers, diagnoses, pharmacologic and surgical interventions as well as the test results that may become known to me in the course of my involvement within any Ballad Health facility. 

In addition, this includes the patient information that may be incidentally disclosed to me as a result of my presence in a Ballad Health facility. I understand that such information will be treated in the same manner as all other patient information and afforded the same level of confidentiality. 

I understand that any breach in confidentiality, including but not limited to any inappropriate use or disclosure of patient information is a violation of Ballad Health policy, and such a breach will result in appropriate actions, up to and including termination of my relationship with Ballad Health. In addition, such a violation may be considered a violation of federal regulations and be subject to investigation by the Office of Civil Rights. 

Confidentiality Principles

• It is an expectation and responsibility of anyone who provides services for or within any Ballad Health facility to insure the utmost privacy and security of patient information. This includes all information whether written, spoken, observed, in a computer system or any other form of media. 
• Patient information will be managed in accordance with Ballad Health policies; and all applicable state and federal requirements. 
• Patient information will only be accessed, used or disclosed in a manner necessary to perform job duties based on a need to know. 
• Patient information will be used or disclosed only as needed to support the purpose of the intended use or disclosure consistent with professional judgment and reasonableness.
• It is an expectation of any.one disclosing patient information to insure they are authorized to do so, to know whether the recipient is authorized to receive the information and to insure the request is appropriate for the content and purpose within professional judgment and reasonableness. 
• It is a patient’s right to expect that their information will be treated in a confidential and secure manner. The patient has the right to expect that their health information will be safeguarded and protected. 
• Patient information will be protected from any intentional or unintentional use or disclosure that is in violation of Ballad Health policy, and/or state and federal regulations. 
• Any breach in confidentiality of patient information is a violation of Ballad Health policy, and such a breach will result in appropriate actions, up to and including the termination of my relationship with Ballad Health. In addition, such a violation may be considered a violation of federal regulations and be subject to investigation by the Office of Civil Rights. 

 

By completing the form below- you agree to the terms of the Confidentiality agreement