ELMHURST MEMORIAL HEALTHCARE
CONFIDENTIALITY AGREEMENT
Name (PRINT): ______________________________________________
Last,
First
Middle Initial
Employee Department/unit: __________________
Physician
Volunteer
Contract/Agency
Instructor
Student
Other: ________________
I understand that information concerning each patient at Elmhurst Memorial
Healthcare is confidential and can only be discussed with individuals
directly involved with that patient’s care, treatment, payment, and related
healthcare operations.
I understand that my computer identification code is equivalent to my
signature and will be used to access only information that is pertinent to my
job and to my relationship, or involvement with Elmhurst Memorial
Healthcare.
I understand that accessing, without valid authorization, my own personal
records or the records of my family members, co-workers, or any patient not
under my care is a breach of confidentiality.
I understand that willful, indiscriminate access of confidential patient or
hospital information is considered sufficient cause for disciplinary action
that may result in my separation from Elmhurst Memorial Healthcare and/or
liability for criminal prosecution.
________________________________
Signature
_________________
Date
Revised 11/02