Hello Ms. McGowin:

Thank you for sharing the Confidentiality Agreement for Visitors to XXXXXXXXXXXXXX Hospital Psychiatric Services document on this site. I had the opportunity to look over the agreement and I have made a few recommendations (shown below) that might boost its effectiveness.  I hope this helps.  Also, thank you for alerting us to the NIST 800-66 DRAFT An Introductory Guide for Implementing the HIPAA Security Rule.  Please let me know if I can be of any further assistance.

Respectfully,

Rick

Richard Piedrahita

Security Analyst

===============

Confidentiality Agreement for Visitors to

XXXXXXXXXXXXXX Hospital Psychiatric Services

  XXXXXXXXXXXXX Hospital System is committed to protecting patient health information.  We have an ethical and legal responsibility to protect the privacy of patients and to maintain the confidentiality of their health information.  While visiting at XXXXXXXXXXXXX Hospital, I do hereby agree to abide by the patient confidentiality policy of Psychiatric Services as explained to me by hospital personnel.

  Any information about patients, even the fact that they are in the hospital, is highly private in nature.  I agree not to RELEASE OR discuss any patient information that I am exposed to during my visit(S) HERE to anyone other than staff members of XXXXXXXXXXXXX Hospital WHOM ARE DIRECTLY INVOLVED WITH THE CARE OF THE PATIENT I AM VISITING.  I understand that under no circumstances should patient information be released or discussed with anyone outside of employees of XXXXXXXXXXXXX Hospital.

  I understand that, should I have any questions about my obligations under this Confidentiality Pledge or under any of the XXXXXXXXXXXXX Hospital System’s policies and procedures and applicable laws and regulations related to confidentiality, I am to discuss my concerns with a SENIOR staff member of Psychiatric Services.  In addition, should I need further information in regards to patient confidentiality, I may contact the XXXXXXXXXXXXXXX Hospital System Privacy Officer at (XXX) XXX-XXXX.

___________________________________________      ________________________

Signature of Visitor/Guest                                                      Date

___________________________________________       ________________________

Signature of Witness                                                              Date

Name of patient with whom you are visiting