Acknowledgement of HIPAA Training

*First name:

*Last name:

Email:

HIPAA (Health Insurance Portability and Accountability Act)

*I understand that as an employee of Crossing Rivers Health, I have a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their health information. It is my responsibility to keep ALL patient information, in all forms (verbal, print, electronic), that I am privileged to see or hear, to safeguard the information by not discussing, showing, or repeating any information to anyone that does not require it in their course and scope of employment. If I violate HIPAA by disclosing a patient’s Protected Health Information, I may lose access to privileges granted by Crossing Rivers Health and be subject to disciplinary action up to and including termination. Willful or malicious release of any information associated with Protected Health Information may result in personal civil or personal criminal liability.

*I have received the HIPAA Privacy and Security training as an employee at Crossing Rivers Health.

*I understand that when necessary, I should seek advice from the appropriate supervisor or Compliance Officer concerning appropriate actions that I may need to take in order to comply with HIPAA.

*I agree to annual HIPAA training sessions as required by law and for employment.

*I agree to report immediately, any suspected or known violations of HIPAA to my supervisor and/or the Compliance Officer.

*I am aware of the 24-hour Compliance Hotline and the phone number is: 608-357-2136

*By signing below, you are stating you completely agree with each statement above and will abide with the federal laws pertaining to HIPAA and to Crossing Rivers Health policies and procedures that pertain to HIPAA standards.

*Volunteer e-Signature (First and Last Name):

*Date:

Volunteer Liaison Signature (First and Last Name):

Date:

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