HIPAA Confidentiality Agreement Form
Please complete this form to acknowledge your understanding of confidentiality requirements and provide your work-access details.
Full Name
*
First Name
Last Name
Role/Job Title
*
Department
*
Please Select
Nursing
Medical Staff
Administration
IT/Systems
Billing
Records Management
Human Resources
Other
Organization/Company
*
Work Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisor/Manager Name
*
Access Type or Reason for Access
*
Direct patient care
Administrative support
Technical support
Billing or claims processing
Quality assurance or compliance
Training or education
Other
Have you completed required privacy and confidentiality training?
*
Yes, completed within the last 12 months
Yes, completed more than 12 months ago
No, not yet completed
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: