PLEDGE OF CONFIDENTIALITY
OF PROTECTED HEALTH INFORMATION (PHI)
It is the policy of MetroSouth Medical Center (MSMC), to maintain patient privacy and
confidentiality at all times. Employees are specifically required to use and/or access protected
health information, only to the extent of the function and duties they are providing as employees
of MSMC. We further maintain that all protected health information, (PHI), will be secured and
continually protected during its collection, use, disclosure, dissemination, storage and destruction
to also detect, deter and prevent identity theft.
All persons associated with MSMC including employees, physicians, contractors, vendors,
auditors, researchers, administrators, members of the Board of Trustees and /or agents of the
above mentioned, shall be bound by this “Pledge of Confidentiality and Privacy of protected
health information (PHI)”, and electronic protected health information, (EPHI).
All MSMC employees and persons associated with MSMC are responsible for protecting the
privacy, security, and confidentiality of all protected health information (PHI), whether oral, written
or in any format, This applies to any PHI that is obtained, handled, learned, heard or viewed,
while in the course of your work or association with MSMC. This includes business or trades
secrets or confidential information made privy by my relationship with the hospital.
Use or disclosure of PHI is acceptable only in the discharge of responsibilities and duties based
on the need to know as minimally necessary. Discussion regarding PHI should not take place in
the presence of persons not entitled to such information or in public places, such as the cafeteria
or off premises of MSMC.
I agree to comply with this pledge of Confidentiality and Privacy of Protected Health Information
during my course of duties here at Metro South Medical Center.
Additionally, I will not impart or make known to any person, or remove from MSMC premises or
make copies of any such data, material or other information, except as authorized to do so in
writing by the privacy officer.
I acknowledge that if I am in possession of a unique I.D. password code to access the electronic
medical record, that it will be used only in keeping with performing my duties.
I am the only individual authorized to use my access code and I will not divulge it to anyone. I will
maintain all HIPAA privacy/confidentiality and information technology security standards to
ensure PHI is safeguarded and not breached.
Finally, I understand that if I breach patient confidentiality, that I may be subject to “Disciplinary
Actions for Breach of Patient Privacy”, also stiff fines including imprisonment may result according
to Federal Statute, under public law 104-191, known as the Health Insurance Portability and
Accountability Act. (HIPAA)
Accepted and Agreed to By:
________________________________________ Date________________________
Signature
Print Name & Title
Revised 6/11
Company Name