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1900 College Drive

Woods & Water Medical Center Rice Lake, WI 54868


(715) 234-7082
ricelake.admissions@witc.edu

CONFIDENTIALITY AND SECURITY AGREEMENT

I understand that Woods & Water Medical Center in which or for whom I work, volunteer, receive
student training, or provide services, or with whom the entity (e.g. physician practice) for which I work
has a relationship (contractual or otherwise) involving the exchange of health information (Woods &
Water Medical Center), has a legal and ethical responsibility to safeguard the privacy of all patients and
to protect the confidentiality of their patients’ health information. Additionally, Woods & Water Medical
Center must assure the confidentiality of its human resources, payroll, fiscal, research, internal
reporting, strategic planning, communications, computer systems and management information
(collectively, with patient identifiable health information, “confidential information”).

In the course of my employment/assignment/student training at Woods & Water Medical Center, I


understand that I may come into the possession of this type of confidential information. I will access and
use this information only when it is necessary to perform my job-related duties in accordance with
Woods & Water Medical Center’s privacy and security policies available on Woods & Water Medical
Center’s information systems. I further understand that I must read, sign, and comply with this
agreement in order to obtain authorization for access to confidential information.

1. I will not disclose or discuss any confidential information with others, including friends or family,
who do not have a need to know it.

2. I will not discuss confidential information where others can overhear the conversation. It is not
acceptable to discuss confidential information even if the patient’s name is not used.

3. I understand that I must safeguard and maintain the confidentiality, integrity, and availability of all
confidential information I use, disclose, and/or access at all times, whether or not I am at work and
regardless of how it was accessed.

4. I will only access, use, and/or disclose the minimum necessary confidential information needed to
perform my assigned duties and disclose it to other individuals/organizations who need it to
perform their assigned duties or as allowed by law.

5. I will not access my own or my family’s medical records in any information system without prior
authorization from the HIM manager (unless required to perform your job duties).

6. I will not make any unauthorized transmissions, inquiries, modifications, or purging of confidential
information. Furthermore, I will not download confidential information off Woods & Water Medical
Center’s system or disc, zip discs, flash drives, other portable media, etc. except in situations where

Created on April 16, 2019


2 CONFIDENTIALITY AND SECURITY AGREEMENT

explicit approval to do so has been granted by the IT department with prior review by the Security
& Privacy officer. If I received this approval to download data I will assume sole and absolute
responsibility to manage and protect it based upon standards listed in the agreement and
according to the law.

7. I will not in any way divulge copy, release, sell, loan, alter, or destroy any confidential information
except as properly authorized.

8. I agree that my obligations under this agreement will continue after my termination of my
employment, expiration of my contract, or my relationship ceases with Woods & Water Medical
Center.

9. Upon termination, I will immediately return any documents or media containing confidential
information to Woods & Water Medical Center.

10. I understand that I have no right to any ownership interest in any information accessed or created
by me during my relationship with Woods & Water Medical Center.

11. I will act in the best interest of Woods & Water Medical Center and in accordance with its code of
ethics at all times during my relationship with Woods & Water Medical Center.

12. I understand that violation of the agreement may result in disciplinary action, up to and including
termination of employment, suspension and loss of privileges, and/or termination of authorization
to work within Woods & Water Medical Center, in accordance with Woods & Water Medical
Center’s policies.

13. I will only access or use systems or devices that I am officially authorized to access and will not
demonstrate the operation or function of systems or devices to unauthorized individuals.

14. I will practice good workstation security measures such as locking the computer when not in use,
using screen savers with activated passwords appropriately, and position screens away from public
view.

15. I will practice secure electronic communications by transmitting confidential information only to
authorized entities, in accordance with approved security standards.

16. I will:
a. Use only my officially assigned User-ID and password.
b. Use only approved licensed software.

17. I will never:


a. Share/disclose User-Ids and passwords.

Created on April 16, 2019


3 CONFIDENTIALITY AND SECURITY AGREEMENT

b. Use tools or techniques to break/exploit security measures.


c. Connect to unauthorized networks through the systems or devices.

18. I will notify my manager or IT if my password has been seen, disclosed, or otherwise compromised,
and will report activity that violates this agreement, privacy and security policies, or any other
incident that could have any adverse impact on confidential information.

19. I have received training on how to protect health information/confidentiality as necessary and
appropriate to perform my job responsibilities.

20. I understand that I will be held accountable for all inquiries, entries, and changes made to any of
Woods & Water Medical Center’s information systems using my Username(s) and password(s).

Refer any questions related to this agreement to the security officer or privacy officer.

By signing this agreement, I agree to comply with its terms and conditions. Failure to read this
agreement is not an excuse for violating it. The IT department may deny access to Woods & Water
Medical Center’s information systems if this agreement is not returned signed and dated.

Employee Signature Date

Employee Printed Name

Return this completed from to Human Resources

Created on April 16, 2019

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