Prince William Area Agency on Aging
5 County Complex Court, Suite 240
Woodbridge, VA 22192
703-792-6400
Fax: 703-792-4734
www.pwcgov.org/aoa
Confidentiality Agreement
I hereby agree and understand that I am accountable in protection of the privacy and confidentiality of
any client information that I may directly or inadvertently see or hear about the Prince William Area
Agency on Aging’s clients and/or clients’ caregivers. I understand the need for Agency on Aging staff
to keep information confidential and will not ask about or seek information from Agency on Aging
staff about their clients.
I agree that I will not disclose to any other person, or allow any other person access to, any information
that is proprietary or confidential and/or pertains to clients, clients’ caregivers, employees, students,
volunteers, and the public. Disclosure of information includes, but it not limited to, verbal discussion,
FAX transmissions, electronic mail messages, voice mail communication, written documentation,
“loaning” computer access codes, and/or other transmissions or sharing of data.
If I observe any incidents where client information is shared with me or other non Agency on Aging
staff, I acknowledge that I am responsible for reporting them to the Agency on Aging management
and will do so.
I understand that, Agency on Aging, Prince William County and its employees, students, volunteers,
clients, and the public, staff or others may suffer irreparable harm by disclosure of proprietary or
confidential information and that the Agency on Aging and Prince William County may seek legal
remedies available to it should such disclosure occur.
______________________________________
Print Name
_________________________________
Witness
______________________________________
Signature
Date
_________________________________
Signature
Date
L:\Confidentiality\confidentiality statement.doc
Empower, Enhance, and Enjoy Aging!
Funding for the Prince William Area Agency on Aging is received from the US Administration on Aging, the Virginia Department for the Aging, Prince William County, and the cities of
Manassas and Manassas Park. The Agency does not discriminate in admission to programs or activities or treatment of employment in programs or activities in compliance with appropriate
state and federal statutes. If you feel you have been discriminated against, you have a right to file a complaint with the Agency by calling 703-792-6400.