[e.g., Janitor, “Plant Lady,” Computer/Technology Specialist, etc.]
I understand that this office provides mental health services, and that I have no authorization to obtain access to client/patient information in any form.
If, in the course of my routine duties, I do see or hear any information about a current or former patient in this office, I understand that this information is to be treated as private and confidential, including the fact that a person has visited this office or receives (or previously received) services through this office.
The privacy and confidentiality of our patients are protected under the Ethics Codes of the mental health professionals who work here; state laws and regulations; and Federal HIPAA Regulations.
I hereby acknowledge, by my signature below, that I understand that any patient information which I see or hear is considered private and confidential. I understand that confidentiality must be maintained whether the information is stored on paper or on computer, or communicated orally or through any other means.
I understand that I am not authorized to seek or deliberately obtain access to patient information. I also understand that employee information of a private or sensitive nature must also be treated as confidential, including employment records, job evaluations, etc. I have been informed that it would be illegal for me to access computerized patient or employee information without authorization of my supervisor.
I understand that unauthorized disclosure of patient information, or any other confidential or proprietary information from this office, is unethical and/or illegal, and that it is grounds for disciplinary action, up to and including my immediate dismissal from employment or termination of my contracted arrangement.
I understand that this duty of confidentiality and non-disclosure will continue to apply even after I am no longer working for this office.
Signature ________________________________________ Date: ______
Witness Signature__________________________________ Date: ______