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VUMC PRIVACY & CONFIDENTIALITY AGREEMENT

OVERVIEW OF PRIVACY POLICIES

Name: __________________________________________ Date of Birth: ____/____/_______
Vanderbilt University Medical Center (VUMC) policy and federal regulations protect the privacy of our patients’
health information. The Health Insurance Portability and Accountability Act (HIPAA) is a set of federal rules that
defines what information is protected, sets limits on how that information may be used or shared, and provides pa-
tients with certain rights regarding their information. VUMC has its own policies that reflect these regulations as
well as best ethical standards.
These rules protect information that is collected or maintained, (verbally, in paper, or electronic format) that can be
linked back to an individual patient and is related to his or her health, the provision of health care services, or the
payment for health care services. This includes, but is not limited to, clinical information, billing and financial
information, and demographic/scheduling information. Even the fact that an individual has received care at VUMC
is protected by VUMC policy and federal regulations.
VUMC policy and HIPAA regulations limit the use or sharing of protected patient information to the following pur-
poses: providing treatment, obtaining payment for services, certain health care administrative functions and when
required or permitted by law. Any other use or disclosure of protected information requires written authorization
from the patient. For all uses or disclosures other than treatment, only the minimum amount of information neces-
sary will be shared on a need to basis. The Notice of Privacy Practices describes to patients how we may use or dis-
close their health
information and patient rights regarding their protected health information

CONFIDENTIALITY AGREEMENT FOR VISITORS IN CLINICAL AREAS

As a visitor at Vanderbilt you are required to conduct yourself in strict conformance to all applicable laws and
Vanderbilt University and VUMC policies governing confidential information. Simply by being in the Medical Cen-
ter, you may encounter confidential patient information. Care is often coordinated in semi-public environments
where there is the risk that patient information may be heard or viewed by individuals not directly involved in the
patient’s care. VUMC has polices intended to limit the risks of such incidental disclosures of patient information.

You may see or hear information related to VUMC patients (such as charts and other paper and electronic records,
demographic information, conversations, admission/discharge dates, names of attending physicians, patient finan-
cial information, etc.). Any patient information you see or hear, either incidentally or by attending rounds, must
be kept confidential. By signing below, you are agreeing to abide by VUMC policies regarding confidentiality of
patient health information.
As a condition of and in consideration of, my use, access, and/or disclosure of confidential information, I,

_______________________________________________________, understand and agree to the following:

 I will access, use, and disclose confidential information only as permitted by VUMC hosts. This means that I will
I attest that I have reviewed the original documentation for all vaccines, X-rays and lab tests marked above only access, use, and disclose confidential information that I have been given authorization to access, use, and dis-
and that the information is complete and accurate to the best of my knowledge: close.
 I understand that any fraudulent application, violation of confidentiality or any violation of the above provisions
Healthcare Provider Printed Name Date will result in the termination of my privilege to observe and participate in rounds in clinical areas and I may be sub-
ject to legal liability as well.
Healthcare Provider Signature
Office Phone Number ( )  My signature below indicates that I have read, accept, and agree to abide by all of the terms and conditions of
Office Address this Agreement and agree to be bound by it.
Mandatory: Add Office or Healthcare Provider Stamp