Confidentiality Statement and Agreement Confidentiality Statement and Agreement Section 1: Confidentiality Statement Section 1: Confidentiality Statement The Engemann Student Health Center (ESHC) honors its ethical and legal obligations to maintain the confidentiality of all patient USC Student Health honors its ethical and legalhonors obligations to maintain theobligations confidentiality of all patient medical information. The Engemann Student Health Center (ESHC) itspatient ethical and legal to maintain confidentiality medical information. Unauthorized use of or access to records is a serious offense and is the strictly prohibited. of all patient Unauthorized use of or access to patient records is a serious offense and is strictly prohibited. medical information. Unauthorized use of or access to patient records is a serious offense and is strictly prohibited. I Iunderstand all patient patientmedical medicalinformation, information,regardless regardless whether is verbal, electronic or documented is to beinheld understand that that all of of whether it isit electronic or documented is to be held the in Ithe understand that all patient medical information, regardless of whether itverbal, is verbal, electronic or documented is to be held in strictest confidence in accordance with state and federal laws and regulations. strictest confidence in accordance with state and federal laws and regulations. the strictest confidence in accordance with state and federal laws and regulations. I Iunderstand patient-relatedinformation informationcan canonly only released by authorized employees of Student the Engemann Student Health understand that that patient-related bebe released by authorized employees of USC Health who obtain the ICenter understand that patient-related information can only be released by authorized employees of the Engemann Student Health who obtain the proper authorization for the release of such information. proper authorization for the release of such information. Center who obtain the proper authorization for the release of such information. I Iunderstand into any anypatient patientrecords recordsunless unlessnecessary necessarytotoperform performmymy normal work-related or assigned duties. understandthat that II cannot cannot look look into normal work-related or assigned duties. I understand that I cannot look into any patient records unless necessary to perform my normal work-related or assigned duties. I Iunderstand priortotoutilizing utilizingthe the PnC Electronic Health Record, I must complete andthe sign PnC EHR Security System Security understand that prior PnC Electronic Health Record, I must complete and sign PnCthe EHR System Access IAccess understand that prior to utilizing the PnC Electronic Health Record, I must complete and sign the PnC EHR System Security Request form my supervisor must and the submit the on request on my behalf. Request form and myand supervisor must sign andsign submit request my behalf. Access Request form and my supervisor must sign and submit the request on my behalf. understandthat thatunder undernono circumstances (except mentioned above or required as required or permitted by law) may I I Iunderstand circumstances (except asas mentioned above or as or permitted by law) Irelease understand that under no circumstances (except as mentioned above or as required or permitted by law) may I any information regarding a patient and/or student thatthat became privileged to me as an employee, student may I release any information regarding a patient and/or student became privileged to me as an employee, release any information regarding a patient and/or student that became privileged to me as an employee, student worker,worker, volunteer or visitor. student volunteer or visitor. worker, volunteer or visitor. Examples useof ofor oraccess accessto tomedical medicalinformation: information: Examplesof ofprivileged/unauthorized privileged/unauthorized use Examples of privileged/unauthorized use of or access to medical information: • If you are in the cafeteria and you see a patient that you saw in the clinic. You cannot say “Hey, I saw you in the clinic on you are are in see a patient thatthat youyou sawsaw in the You cannot say “Hey, saw you in the clinic on Friday.” • • IfIfyou in the thecafeteria cafeteriaand andyou you see a patient inclinic. the clinic. You cannot sayI “Hey, I saw you in the clinic on Friday.” You cannot tell anyone that you saw any patient in the clinic. The fact that the patient was seen at the ESHC is You cannot tell anyone that you saw any patient in the clinic. The fact that the patient was seen at USC Student Health is confidential. Friday.” You cannot tell anyone that you saw any patient in the clinic. The fact that the patient was seen at the ESHC is confidential. • confidential. You happen to see test results of someone you know. You cannot tell them you saw the results, “Your throat culture was negative.” • You happen to see test results of someone youtest, know. You cannot tell them you saw the results, “Your throat culture was And you cannot tell anyone else the results of the “John Doe was positive for mono.” • You happen to see test results of someone you know. You cannot tell them you saw the results, “Your throat culture was negative.” And you cannot tell anyone else the results of the test, “John Doe was positive for mono.” Andmedical you cannot tell anyone else the results of that the test, “John Any Doeinformation was positivethat for you mono.” • negative.” You hear two professionals discussing a patient you know. hear is confidential and • You hear two medical professionals discussing a patient that you know. Any information that you hear is confidential and cannot be repeated. • cannot You hear medical professionals discussing a patient that you know. Any information that you hear is confidential and betwo repeated. cannot be repeated. Youare are reviewing reviewing medical thethe name andand decide to find outout whywhy the the • • You medical records recordsfor forappointments, appointments,lab labfiling, filing,etc. etc.You Yourecognize recognize name decide to find • patient You are isreviewing medical records for appointments, lab filing, etc. You recognize the name and decide to find out why patient iscoming comingin in to be seen. You cannot read or access any patient-related confidential information that is not part of to You cannot read or access any patient-related confidential information that is not part your ofthe patient is coming in to be seen. You cannot read or access any patient-related confidential information that is not part of work-related duties. You cannot release any confidential information you might during course work.of work. your work-related duties. You cannot release any confidential information yousee might see your during yourof course your work-related duties. You cannot release any confidential information you might see during your course of work. • • You hear about aa USC student in inthe thenews newsand andyou youare arecurious curiousif if they have been to the ESHC. Health. You cannot access the You hear about USC student they have been to USC Student You cannot • electronic You hear about a of USC studentwhen in thesuch newsaccess and you are curious ifnormal they have been to the ESHC. You cannot accesstoaccess the record a patient is outside your work-related duties without permission the electronic record of a patient when such access is outside your normal work-related duties withoutpermission permissiontotoaccess accessthe electronic record of a patient when such access is outside your normal work-related duties without access the record from your supervisor. the record from your supervisor. record from your supervisor. I I understand thatasasa USC an ESHC employee, student student worker, worker, volunteer or visitor, I amI am required totoabide policies and and understand Student Health employee, volunteer or visitor, required abideby by all all policies Iprocedures understandofthat that as an ESHC employee, student worker, volunteer or visitor, I am required torules abide by all policiesand andI the Engemann Student Health Center and uphold all ethical and legal confidentiality and regulations procedures of USC Student Health and uphold all ethical and legal confidentiality rules and regulations and I promise and warrant procedures ofwarrant the Engemann Student Health Center uphold all ethical and legal confidentiality rules and regulations andtoI promise I will comply with all suchI and rules and regulations. I understand that ESHC tracks individual access that I willand comply withthat all such rules and regulations. understand that USC Student Health tracks individual access to electronic promise and warrant that I will comply with all such rules and regulations. I understand that ESHC tracks individual access to electronic medical records. medical records. electronic medical records. I Iunderstand understandthat thatany anybreach breachof ofconfidentiality confidentiality isislikely likelyto to result result in in disciplinary disciplinaryaction, action,up upto toand andincluding includingtermination terminationof of my my Iemployment understand that any breach of confidentiality is likely to result in disciplinary action, up to and including termination of my a ofSouthern SouthernCalifornia, California,and andthat thatUSC ESHC may be required to required report the circumstances of such employment at at the the University University of Student Health may be to full report the full circumstances employment at and the University of Southern California, and that ESHC may be required to report the full circumstances of such a breach state federal authorities. of suchtoa breach to state and federal authorities. breach to state and federal authorities. I Ihave to ask ask questions and and obtain obtain haveread readand andfully fullyunderstand understandthe the significance significanceof of this this statement statement and and have had the opportunity to Isatisfactory have read and fully understand the significance of this statement and have had the opportunity to ask questions and obtain answers before signing my name. satisfactory answers before name. satisfactory answers before signing my name. Section 2: Visitor Information Section 2: Visitor Information USC Affiliation ☐ Employee/Student Worker ☐ Intern ☐ Volunteer ☐ Visitor From_____________ ☐ Other:_________ USC Affiliation ☐ Employee/Student Worker ☐ Intern ☐ Volunteer ☐ Visitor From_____________ ☐ Other:_________ Name (Last, First) Name (Last, First)
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1031 W. 34th Street, Los Angeles, California 90089-3261 • (213) 740-9355 1031 W. 34th Street, Los Angeles, California 90089-3261 • (213) 740-9355