Non-Employee Identification Badge Verification Form
I. Type of Badge Required (please circle):
Auxiliary Volunteers
Contractor
Disaster Volunteer
Medical Staff Members
Supplier/Vendor
Clergy
Associates Employed by
Physicians
Student/ Intern
Pastoral Visitor
II. BVHS Department- Department Manager
Department Name
____Pharmacy_________________________________
Department Manager Name ___Michael Leifheit_______________________________________
Department Manager Signature _____________________________________________________
Activation Date of Badge (required for all students, contractors) _________ to ____________
* All badges will be required to have an expiration date. At a minimum all badges will be re-certified every six months for students,
contractors, and suppliers.
III. Personal Information- Applicant
Name ______________________________________________________________________
Address ____________________________________________________________________
City _____________________
Telephone Number (
State _________________
Zip ______________
) ______________________
Business Information
Employer ___________________________________________________________________
Contact Person _______________________________________________________________
Telephone Number (
) ______________________
Agreement:
_____I agree to wear badge at all times while completing duties at BVHS.
_____I agree to wear badge above the waist in an area that is easy for others to see.
_____I agree to return the badge to my immediate supervisor and/or the Human Resource Department upon
completing my assignment or contract at BVHS.
_____I recognize that failure to follow the above guidelines may result in the loss of my privileges at BVHS.
Name (printed) __________________________________________________________________
Signature ______________________________ Date ___________________________________
IV. Human Resources
Badge Issued by __________________________________________Date __________________
Expiration Date on Badge _________________________________
CONFIDENTIALITY AGREEMENT
(To be signed by workforce members, including associates, volunteers, students, temporary staff and contractors)
This statement summarizes the responsibilities and obligations of all members of the Blanchard Valley
Health System (BVHS) workforce who use, create, or receive protected health information (PHI). It is
the responsibility of all persons granted access to PHI to protect the confidentiality of our
patient/resident/customer’s information and to make use or disclose information only to the extent
authorized and necessary to provide patient care or perform necessary job functions to fulfill health
care operations on behalf of BVHS.
I _________________________________________ (insert name) recognize and acknowledge that
all protected health information (PHI) maintained by BVHS is sensitive and confidential. By reason of
my job responsibilities, I may come into possession of this PHI. I agree that I will not, at any time
during or after my employment or term of service, improperly use or disclose PHI to anyone outside of
BVHS or with other BVHS workforce members. I agree that I will only use or disclose PHI as
necessary to perform my job responsibilities and in accordance with BVHS’s privacy policies.
I agree to take necessary precautions to reduce the risk of incidentally disclosing PHI to unauthorized
individuals. For example, I will avoid discussing PHI in public areas (such as the cafeteria, elevator,
etc.) where there is an increased risk of the conversation being overheard; I will safeguard PHI in my
possession against unauthorized access (e.g. avoid leaving PHI displayed on computer monitor, will
not leave PHI in an open, unattended area, etc).
I recognize that the sharing of access privileges (passwords, badges, access codes) assigned to me is
prohibited and I am accountable for them and any improper access of information that may be gained.
I will take reasonable measures to protect my access privileges. If I have reason to believe that my
access privileges have been compromised, I will immediately notify my Director, the Information
Technology department and/or the Privacy Officer.
I acknowledge that it is strictly prohibited to access my own PHI or that of relative, friend, another
associate, etc. unless in accordance with my job responsibilities or with appropriate authorization.
Activities in the Meditech and other BVHS computer systems are tracked and audits are conducted.
Any inappropriate access is grounds for immediate dismissal and possible legal action.
I also recognize that it is my responsibility to report any inappropriate use or disclosure of PHI that I
may observe or become aware of to my manager or the Privacy Officer.
I acknowledge that inappropriate use or disclosure of PHI and/or any violation of BVHS’s privacy
policies may result in disciplinary action including immediate dismissal and possible legal action.
_________________________________________
Name (Printed)
__________________________________________________
Signature
__________________________________________________
Witness Signature
__________________________________________________
Date
Signed copy provided to above individual on: __________________________________________________
(January 2009)