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Confidentiality Agreement


The following rules for Confidentiality and Network Access apply to all non-public patient and business information (Confidential Information) of Holy Cross Hospital, Trinity Health, and related organizations. The rules also apply to the non-public and business information of joint ventures, or of other entities and persons collaborating with the Holy Cross Hospital and Trinity Health, to which the user has access. As a condition of being permitted to have access to Confidential Information relevant to my job function or role I agree to the following rules:


* Indicates required information

First Name * 

Last Name * 

1. Permitted and required access, use and disclosure:  

I will access, use or disclose Confidential Patient Information (PHI) only for legitimate purposes of diagnosis, treatment, obtaining payment for patient care, or performing other health care operations functions permitted by HIPAA. * 

I will only access, use or disclose the minimum necessary amount of information needed to carry out my job responsibilities. * 

I will access, use or disclose Confidential Business Information only for legitimate business purposes of Holy Cross Hospital or Trinity Health. * 

I will protect all Confidential Information to which I have access, or which I otherwise acquire, from loss, misuse, alteration or unauthorized disclosure, modification or access including:  

Making sure that paper records are not left unattended in areas where unauthorized people may view them;  * 

Using password protection, screensavers, automatic time-outs or other appropriate security measures to ensure that no unauthorized person may access Confidential Information from my workstation or other device; * 

Appropriately disposing of Confidential Information in a manner that prevents a breach of confidentiality and never discarding paper documents or other materials containing Confidential Information in the trash unless they have been shredded * 

Safeguarding and protecting portable electronic devices containing Confidential Information including laptops, smartphones, PDAs, CDs, and USB thumb drives. * 

I will disclose Confidential Information only to individuals, who have a need to know to fulfill their job responsibilities and business obligations.  * 

I will comply with Holy Cross Hospital/Trinity Health's access and security procedures, and any other policies and procedures that reasonably apply to my use of the computer systems. * 

I will comply with Hospital/Trinity Health's access and security procedures and any other policies and procedures that apply to my access to information on or related to the systems including off-site access using portable electronic devices * 

2. Prohibited access, use and disclosure: 

I won't access, use or disclose Confidential Information in electronic, paper or oral forms for any purpose not permitted by the Hospital/Trinity Health policy, including information about coworkers, family, friends, celebrities. * 

I will follow the required procedures at Holy Cross Hospital to gain access to my own PHI in medical and other records. * 

I will not use another person’s, login ID, password, other security device or other information that enables access to Trinity Health's computer systems or applications nor will I share my own with any other person.  * 

If my employment or association with Holy Cross Hospital/Trinity Health ends, I will not subsequently access, use or disclose any Holy Cross Hospital/Trinity Health Confidential Information and will promptly return any security devices and other property. * 

I will not engage in any personal use of the Hospital’s computer systems that interferes with the productivity of employees or others associated with the Hospital/Trinity Health’s operations or business or that is intended for personal gain * 

I will not engage in the transmission of information which is disparaging to others based on race, national origin, sex, sexual orientation, age, disability or religion. * 

I will not engage in the transmission of information which is is otherwise offensive, inappropriate or in violation of the mission, values, policies or procedures of Trinity Health; * 

I will not utilize the Holy Cross Hospital/Trinity Health network to access Internet sites that contain content that is inconsistent with the mission, values and policies of Holy Cross Hospital/ Trinity Health. * 

3. Accountability and sanctions: 

I will immediately notify the Hospital/Trinity Health Security/Privacy Official if I think there has been improper/unauthorized access to the network or improper use or disclosure of confidential information in electronic, paper or oral form * 

I understand that Holy Cross Hospital/Trinity Health will monitor my access to, and my activity within, Trinity Health’s computer system, and I have no rightful expectation of privacy regarding such access or activity. * 

I understand that if I violate any of the requirements, I may be subject to disciplinary action, my access may be suspended or terminated and/or I may be liable for breach of contract and subject to substantial civil damages and/or criminal penalties. * 

If I lose my security device I will report the loss to the Trinity Health Resolution Center immediately and I may be charged for its replacement. * 

4. Software Use 

I understand that my use of the software on Trinity Health’s network is governed by the terms of separate license agreements between Trinity Health and the vendors of that software. * 

I agree to use such software only to provide services to benefit Trinity Health.  * 

I will not attempt to download, copy or install the software on any other computer. * 

I will not make any change to any of Trinity Health’s systems without Trinity Health’s prior express written approval. * 

5. Network  

I understand that access to Trinity Health’s network is “as is”, with no warranties and all warranties are disclaimed by Trinity Health.  * 

Trinity Health may suspend or discontinue access to protect the network or to accommodate necessary down time. In an emergency or unplanned situation Trinity Health may suspend or terminate access with out advance warning. * 

Trinity Health may terminate this agreement, user access and use of Confidential Information at any time for any reason or no reason.  * 

If there are any items in this agreement that I do not understand I will ask my Holy Cross Hospital supervisor or other appropriate Holy Cross Hospital contact person for clarification.  

My signature below acknowledges that I have read, understand and accept this agreement and realize it is a condition of my employment or association with Trinity Health.  

I also acknowledge that I have received a copy of the Confidentiality and Network Access Agreement. 

Print Name * 

Electronic signature of individual to be given access  * 

Date * 


If I am under the age of 18 and unemancipated, I must have a parent or guardian sign this Agreement on my behalf. 

Parent Signature 

©  2014 

Holy Cross Hospital | 1500 Forest Glen Road, Silver Spring, MD 20910 | 301-754-7000