Laserfiche WebLink
HIPAA Privacy Rule Employee <br />Confidentiality Form <br />I, ,have read and understand Elk River Municipal <br />(Employee Name) <br />Utilities policies regarding the privacy of individually identifiable health information <br />(or protected health information (PHI), as mandated by the Health Insurance <br />Portability and Accountability Act of 1996 (HIPAA) and the State of Minnesota. In <br />addition, I acknowledge that I have received training in Elk River Municipal Utilities <br />policies concerning PHI use, disclosure, storage and destruction as required by HIPAA. <br />In consideration of my employment or compensation from Elk River Municipal <br />Utilities, I hereby agree that I will not at any time -either during my employment or <br />association with Elk River Municipal Utilities or after my employment or association <br />ends -use, access or disclose PHI to any person or entity, internally or externally, <br />except as is required and permitted in the course of my duties and responsibilities with <br />Elk River Municipal Utilities, as set forth in Elk River Municipal Utilities privacy <br />policy and procedures or as permitted under HIPAA. I understand that this obligation <br />extends to any PHI that I may acquire during the course of my employment or <br />association with Elk River Municipal Utilities, whether in oral, written or electronic <br />form and regardless of the manner in which access was obtained. <br />I understand and acknowledge my responsibility to apply Elk River Municipal Utilities <br />policies and procedures during the course of my employment or association. I also <br />understand that unauthorized use or disclosure of PHI will result in disciplinary action, <br />up to and including termination of employment or association with Elk River <br />Municipal Utilities and the imposition of civil penalties and criminal penalties under <br />applicable federal and state law, as well as professional disciplinary action as <br />appropriate. <br />I understand that this obligation will survive the termination of my employment or end <br />of my association with Elk River Municipal Utilities, regardless of the reason for such <br />termination. <br />Signature Date <br />Name <br />