Your Clinic Letterhead

Confidentiality Oath for Custodians

  1. I, ______agree that I will faithfully discharge my duties as a custodian working for (CLINIC NAME),and will observe and comply with all policies and procedures of the Clinic with respect to privacy, confidentiality, and security of health information.

I further acknowledge clinic specific Information Handling and Security practices which includes

  1. Information Handling and Security procedures
  2. Laptop Security
  3. Wireless Networking / Remote Access policies
  1. Unless legally authorized to do so, I will not use or disclose health information that comes to my knowledge or possession by reason of my affiliation with the Clinic, including after I cease to be employed at the Clinic.
  1. I understand that a breachof this agreement may be just cause for termination of my employment or affiliation with the Clinic.
  1. I am aware that the Clinic has policies and procedures regarding the privacy, confidentiality, and security of health information and I understand that it is my responsibility to be familiar with the requirements outlined in these policies and procedures.
  1. My use of the Clinic’s electronic medical record, Netcare and other electronic applications may be monitored to ensure appropriate confidentiality, and security. Specifically, audit and access logs will be checked by the system administrator if a breach of security or privacy is suspected. The clinic will work with the vendor to automatically generate audit logs that identify use of the system outside of office hours, same last name (of user and patient record look-up), and similar monitoring criteria. A participating custodian and authorized affiliate may access and use information in Alberta Netcare or other e-Health networks when:
  1. They are in a current care relationship with the individual who is the subject of the information;
  2. They are providing health services to the individual either in the presence or absence of that individual;
  3. Their access to the information is necessary for the provision of the health services or for making a determination for a related health service; and
  4. The information is related to and necessary for the current session of care.
  1. I understand that I can refer to the Clinic Privacy Officer (PRIVACY OFFICER NAME) for the details of these policies and any other information required for me to understand my obligations.
  1. I am aware of (CLINIC NAME)’sHealth Information Privacy and Security Manual and will follow the policies and procedures to meet our custodial responsibility to establish and adopt policies and procedures to facilitate the implementation of the Health Information Act and good business practices.

Dr. NAMEhas submitted to the OIPC a Privacy Impact Assessment (OIPC File H____) submission for (PROJECT NAME)that describes the safeguards relating to the collection, use and disclosure of individually identifying health information. I am willing to abide by these policies, procedures, requirements.

I am aware of the Information Manager Agreement with Alberta Netcare and aware of and bound to the Privacy Impact Assessments H1124 (Alberta Netcare) and H3879 (Alberta Netcare Portal which is a web-based portal application that enables the electronic viewing of health information) Alberta Health has done for Alberta Netcare.

I understand that the following Information Managers provide specific services and management of patient health information. There are separate written agreements with each of these service providers and are available to me for review.

Information Manager:

Service:

Information Manager:

Service:

Information Manager:

Service:

Custodian’s Name and Signature:
Date:
  1. (for custodians declaring as an affiliate) (Health Information Act Regulations 2.1)

I ______as a health service provider who is designated

(print name)

in the regulations as a custodian or who is within a class of health service providers that is designated in the regulations as ______(registered member of named professional association)

declare myself as an affiliate as defined by the Health Information Act while in the employment or contract to Dr. NAME of CLINIC NAME.

I understand that I am obligated to follow the policies and procedures Dr. NAME and am of the opinion that Dr. NAME will continue to provide individuals (patients) reasonable access to their personal health information.

Accepted by: / Declared by:
Dr.NAME
Date: / Date:

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