I understand that I may, during the course of my visit to or volunteer/trainee service at Cameron
University, Health Plan hear, see, and/or otherwise come into contact University Health Plan Member
information of a medical and/or personal nature (“Information”). Therefore, I, the undersigned, do
hereby affirm that I will:
1. Protect and safeguard this Information from any oral and/or written disclosure and not disclose
any Information to third parties, including family members, students, faculty members, or other
health care providers or health plans.
2. Not view or copy Member insurance-related medical or billing records or similar documents,
except as specifically allowed by the University Health Plan. I may not use any Information in
presentations, reports, or publications of any kind without the University Health Plan’s prior
3. Not release Information from any record source to any unauthorized person without the
University Health Plan’s prior written approval.
4. Restrict my own access to Information, if any, to that which is essential for and minimally
necessary to the proper completion of my responsibilities while visiting or volunteering at the
University Health Plan.
5. Complete any training required by the University Health Plan, including but not limited to
HIPAA Privacy and Security training.
I understand that all University and University Health Plan policies on confidentiality and this
Agreement apply equally to Information stored on paper records, electronically, or on any other
Finally, I understand that any misuse of Information from a Member’s record or elsewhere, or
any violation of the principles of confidentiality, whether intentional or due to neglect on my part,
will be grounds for immediate exclusion from future participation in programs sponsored or held by
the University Health Plan.
Participant (or legal representative* if participant is a
Date(s) intended to be on Campus
Department Representative Phone Date
*May be requested to show proof of representative status.
Rev. 1/2015 © 2015 File in Department