HIPPA Acknowledgment
In accordance with the privacy regulations promulgated under the Health Insurance Portabilityand Accountability Act, 45 (forty-five) CFR parts 160 and 164 (the “Privacy Regulations”),Nurses Direct, L.L.C., and Nurses Direct Employee understand and agree to abide by the Facility privacy policies and to not use or further disclose a patient’spersonal health information except as expressly permitted by the Agreement or as otherwiseauthorized in writing by the patient through a consent or authorization meeting the requirementsof the Privacy Regulations. Nurses Direct, L.L.C. and Nurse Employee may only use a patient’s personal healthinformation for the sole purpose of treatment, and/or health care operations and may not releaseany information to unauthorized parties. Nurses Direct, L.L.C. and Nurse Employee agree toimplement appropriate safeguards to prevent the unauthorized use and disclosure of any patient’spersonal health information received by Facility under this Agreement. In addition NursesDirect, L.L.C. and Nurse Employee shall make available to the Facility the protected healthinformation for amendment purposes, should changes to the information be necessary or toprovide an accounting of disclosures of the protection health information.If any unauthorized disclosure of personal health information occurs, Nurses Direct, L.L.C., andNurse Employee shall immediately contact Facility to inform them of the disclosure and anyremedial action taken to prevent further disclosures Nurses Direct, L.L.C., and NurseEmployee understand that any unauthorized disclosure of a patient’s personal health informationis grounds for immediate termination of the Agreement and/or a staffing assignment.
Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
Date
HIPPA Acknowledgment
*
In accordance with the privacy regulations promulgated under the Health Insurance Portabilityand Accountability Act, 45 (forty-five) CFR parts 160 and 164 (the “Privacy Regulations”),Nurses Direct, L.L.C., and Nurses Direct Employee understand and agree to abide by the Facility privacy policies and to not use or further disclose a patient’spersonal health information except as expressly permitted by the Agreement or as otherwiseauthorized in writing by the patient through a consent or authorization meeting the requirementsof the Privacy Regulations. Nurses Direct, L.L.C. and Nurse Employee may only use a patient’s personal healthinformation for the sole purpose of treatment, and/or health care operations and may not releaseany information to unauthorized parties. Nurses Direct, L.L.C. and Nurse Employee agree toimplement appropriate safeguards to prevent the unauthorized use and disclosure of any patient’spersonal health information received by Facility under this Agreement. In addition NursesDirect, L.L.C. and Nurse Employee shall make available to the Facility the protected healthinformation for amendment purposes, should changes to the information be necessary or toprovide an accounting of disclosures of the protection health information.If any unauthorized disclosure of personal health information occurs, Nurses Direct, L.L.C., andNurse Employee shall immediately contact Facility to inform them of the disclosure and anyremedial action taken to prevent further disclosures Nurses Direct, L.L.C., and NurseEmployee understand that any unauthorized disclosure of a patient’s personal health informationis grounds for immediate termination of the Agreement and/or a staffing assignment.
I agree:
*
to abide by all facility policies in regards to HIPPA.
Signature
*
Submit
Should be Empty: