Termination Nondisclosure Agreement for Employees/Students/Volunteers
[Name of healthcare provider] has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of my employment/assignment at [name of healthcare provider], I may have come into possession of or overheard confidential patient information, even though I may not have been directly involved in providing patient services.
I understand that such information must be maintained in the strictest confidence. I hereby agree that I will not at any time after my employment/assignment with [name of healthcare provider] disclose any patient information, in any form, to any person whatsoever.
I understand that violation of this agreement may result in civil action.
Signature of Employee/Student/Volunteer Witness
Note: This sample form was developed for AHIMA for discussion purposes. It should not be used without review by your organizations legal counsel to ensure compliance with local and state laws.
|Source: AHIMA Practice Brief, Journal of AHIMA 74, no.6 (2003), 64C.|