Privacy and Confidentiality Acknowledgement Statement

Employee Name (Please print):

Position Title:

As a Cathedral Square employee, I understand that I have a legal and ethical obligation to protect the privacy, confidentiality and security of any medical records to which my job may require access and all other confidential information related to our residents, Support And Services at Home (SASH) participants, employees, board members, providers, other stakeholders, and Cathedral Square business operations in compliance with the Confidentiality Policy – 1.5 in our Employee Handbook.

I understand and acknowledge that:

1. I shall only access resident and SASH participant records and other confidential information that I need to perform my job and for which I am authorized.

2. I shall only disclose confidential information to persons who are authorized to receive this information to enable me to perform my job.

3. I shall only discuss confidential information in private settings, where such discussions will not be overheard by persons not authorized to receive such information.

4. I shall not discuss confidential information concerning Cathedral Square’s residents, SASH participants, employees or business operations outside of the workplace.

5. I understand that there is a record of my computer password when I access electronic records and that I am the only person who is authorized to use my user password.

6. I understand that my obligation to protect resident and SASH participant privacy continues even if I am no longer employed by Cathedral Square.

7. I will take reasonable care to properly secure confidential information on my computer and will take steps to ensure that others cannot view or access such information.

8. I will not disclose my personal password(s) to anyone without the approval of my supervisor. I will not record or post my password in an accessible location and I will refrain from performing any tasks using another’s password.

9. I understand that if I fail to comply with the policies and procedures that have been adopted by Cathedral Square to protect resident and SASH participants’ privacy, I will be subject to disciplinary action, up to and including termination.

Employee Signature:__________________________________ Date:__________________________

Privacy Officer:______________________________________ Date:__________________________