You are on page 1of 3

Woods & Water Medical Center

1900 College Drive • Rice Lake, WI 54868 • (715) 234-7082 • WWMC.com

CONFIDENTIALITY AND SECURITY AGREEMENT

I understand that Woods & Water Medical Center in which or for whom I work, volunteer, receive student training, or
provide services, or with whom the entity (e.g. physician practice) for which I work has a relationship (contractual or
otherwise) involving the exchange of health information (Woods & Water Medical Center), has a legal and ethical
responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients’ health
information. Additionally, Woods & Water Medical Center must assure the confidentiality of its human resources,
payroll, fiscal, research, internal reporting, strategic planning, communications, computer systems and management
information (collectively, with patient; identifiable health information, “confidential information”).

In the course of my employment/assignment/student training at Woods & Water Medical Center, I understand that I
may come into the possession of this type of confidential information. I will access and use this information only when it
is necessary to perform my job-related duties in accordance with Woods & Water Medical Center’s privacy and security
policies available on Woods & Water Medical Center’s information systems. I further understand that I must read, sign,
and comply with this agreement in order to obtain authorization for access to confidential information.

1. I will not disclose or discuss any confidential information with others, including friends or family, who do not have a
need to know it.

2. I will not discuss confidential information where others can overhear the conversation. It is not acceptable to
discuss confidential information even if the patient’s name is not used.

3. I understand that I must safeguard and maintain the confidentiality, integrity, and availability of all confidential
information I use, disclose, and/or access at all times, whether or not I am at work and regardless of how it was
accessed.

4. I will only access, use, and/or disclose the minimum necessary confidential information needed to perform my
assigned duties and disclose it to other individuals/organizations who need it to perform their assigned duties or as
allowed by law.

5. I will not access my own or my family’s medical records in any information system without prior authorization from
the HIM manager (unless required to perform your job duties).

6. I will not make any unauthorized transmissions, inquiries, modifications, or purging of confidential information.
Furthermore, I will not download confidential information off Woods & Water Medical Center’s system or disc, zip
discs, flash drives, other portable media, etc. except in situations where explicit approval to do so has been granted
by the IT department with prior review by the security & privacy officer. If I received this approval to download
data, I will assume sole and absolute responsibility to manage and protect it based upon standards listed in the
agreement and according to the law.
7. I will not in any way divulge, copy, release, sell, loan, alter, or destroy any confidential information except as
properly authorized.
8. I agree that my obligations under this agreement will continue after my termination of my employment, expiration
of my contract, or my relationship ceases with Woods & Water Medical Center.

9. Upon termination, I will immediately return any documents or media containing confidential information to Woods
& Water Medical Center.

10. I understand that I have no right to any ownership interest in any information accessed or created by me during my
relationship with Woods & Water Medical Center.

11. I will act in the best interest of Woods & Water Medical Center and in accordance with its code of ethics at all times
during my relationship with Woods & Water Medical Center.

12. I understand that violation of the agreement may result in disciplinary action, up to and including termination of
employment, suspension, and loss of privileges, and/or termination of authorization to work within Woods &
Water Medical Center, in accordance with Woods & Water Medical Center’s policies.

13. I will only access or use systems or devices that I am officially authorized to access and will not demonstrate the
operation or function of systems or devices to unauthorized individuals.

14. I will practice good workstation security measures such as locking the computer when not in use, using screen
savers with activated passwords appropriately, and position screens away from public view.

15. I will practice secure electronic communications by transmitting confidential information only to authorized
entities, in accordance with approved security standards.

16. I will:
a. Use only my officially assigned user-ID and password.
b. Use only approved licensed software.

17. I will never:


a. Share/disclose user-IDs and passwords.
b. Use tools or techniques to break/exploit security measures.
c. Connect to unauthorized networks through the systems or devices.

18. I will notify my manager or IT if my password has been seen, disclosed, or otherwise compromised, and will report
activity that violates this agreement, privacy and security policies, or any other incident that could have any
adverse impact on confidential information.

19. I have received training on how to protect health information/confidentiality as necessary and appropriate to
perform my job responsibilities.

20. I understand that I will be held accountable for all inquiries, entries, and changes made to any of Woods & Water
Medical Center’s information systems using my username(s) and password(s).

Refer any questions related to this agreement to the security officer or privacy officer.
By signing this agreement, I agree to comply with its terms and conditions. Failure to read this agreement is not an
excuse for violating it. The IT department may deny access to Woods & Water Medical Center’s information systems if
this agreement is not returned signed and dated.

Employee Signature Date

Employee Printed Name

Return this completed form to Human Resources

You might also like