Student Externship Confidentiality Agreement

By Signing this Confidentiality Agreement you are agreeing to the following:

  1. I will keep all patient information confidential. I will disclose patient information in accordance with the policies of the facility that I am assigned to during my student externship experience. Furthermore, I understand and agree to comply with the guidelines set forth by HIPAA.
  2. I will not discuss any information, patient-related or relating to the operations of the facility including my own health record if applicable.
  3. I will keep all security codes and passwords used to access the facility, equipment, and computer systems confidential.
  4. I will access or view patient information only as it is required in the scope of my student experience to include my own health record if applicable.
  5. I will not disclose, copy, transmit, modify or destroy patient information or other confidential practice information without the permission of my supervisor or the practice’s privacy officer.
  6. I agree to comply with these conditions even after my student externship experience is terminated.
  7. I understand the violation of this agreement may result in disciplinary action, up to and including termination from the externship and dismissal from my program.

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Signature Certificate
Document name: Student Externship Confidentiality Agreement
lock iconUnique Document ID: ec2e2691ae3319ac3c453382cd7c6e8f64f7efc1
Timestamp Audit
April 27, 2022 10:16 AM EDTStudent Externship Confidentiality Agreement Uploaded by MedCertify Education - [email protected] IP 2600:1700:7b18:ec90:f519:77dc:9e72:7bd5
April 29, 2022 9:44 AM EDTMedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip:
May 2, 2023 1:22 PM EDTMedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: