Fillable Form 2870: CONFIDENTIALITY AGREEMENT

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Form 2870: CONFIDENTIALITY AGREEMENT

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2870 NCAL 01/26/2012 15
2870
CONFIDENTIALITY AGREEMENT
Instructions: 1. To ensure efficient and effective service, submit form online. Immediate confirmation will be sent to you upon
receipt of your online submittal.
2. If online submittal is not feasible, fax your form to HR Service Center (877) 477-2329 or interoffice mail to HR Service
Center, Alameda.
3. Remember to print copy of form before submitting.
4. The Effective Date represents the date the Confidentiality Agreement is signed.
* Employee First Name Employee Middle Name * Employee Last Name
* Employee ID
* Work Phone Number (###) ###-####
* Effective Date (mm/dd/yyyy)
Page 1 of 3
In my job, I may see or hear confidential information in any form (oral, written, or electronic) regarding:
- HEALTH PLAN MEMBERS AND PATIENTS AND/OR THEIR FAMILY MEMBERS (such as patient records, test results,
conversations, financial information)
- EMPLOYEES, PHYSICIANS, VOLUNTEERS, CONTRACTORS (such as employment records, corrective
actions/disciplinary actions)
- BUSINESS INFORMATION (such as member rates, marketing plans, financial projections)
I will protect the confidentiality of this information. Access to this information is allowed only if I need to know it to do my job.
I AGREE THAT:
1. I will protect the privacy of our patients, members, and employees.
2. I will not misuse confidential information of patients, members, employees or Kaiser Permanente (including confidential business
and personnel information) and I will only access information I have been instructed or authorized to access to do my job. With
respect to Protected Health Information, I will only access or use such information as it is necessary to provide medical care to the
member and/or patient or as necessary for billing and payment or health plan operations.
3. I will not access my family members' PHI. I will not access my own medical records unless my job duties authorize me to have
access to electronic medical records (for example, KP HealthConnect). Instead, I will follow the same procedures that apply to
non-employee health plan members.
4. I will not share, change, remove or destroy any confidential information unless it is part of my job to do so. If any of these tasks are
part of my job, I will follow the correct department procedure or the instructions of my supervisor/chief of service (such as shredding
confidential paper). If a demand is made upon me from outside Kaiser Permanente to disclose confidential information, I will obtain
approval from my supervisor before disclosing such information.
5. I understand that inappropriate or unauthorized access, use or disclosure of PHI may result in legally required reporting to
governmental authorities, including my name.
6. I know that confidential information I learn on the job does not belong to me and that Kaiser Permanente may take away my access
to confidential information at any time.
7. If I have access to electronic equipment and/or records, I will keep my computer password secret and I will not share it with any
unauthorized individual. I am responsible if I fail to protect my password or other means of accessing confidential information.
8. I will not use anyone elses password to access any Kaiser Permanente system unless I am authorized to do so. If I am authorized
to do so (e.g., in order to perform computer systems maintenance), I will follow procedures to ensure the password is changed and
that confidential information is not at risk.
9. I will lock my computer when I step away to prevent someone else accessing the computer under my logon. I understand that I am
personally responsible for any accesses under my logon.
10. If I leave Kaiser Permanente I will not share any confidential information that I learned or had access to during my employment.
11. On termination of my employment, I will promptly return to Kaiser Permanente all originals and copies of documents containing
Kaiser Permanente's information or data in my possession or control, unless the documents were provided to me as part of my
employment record.
AGREEMENT
* Job Title * Location
HR Service Center
Fax to: (877) 477-2329
Telephone: (877) 457-4772
Executives: Contact your Executive Benefits Specialist
Page 1 of 3
Next Page >
2870 NCAL 01/26/2012 15
2870
* First Name Middle Name * Last Name
* Employee ID
* Work Phone Number (###)###-####
* Effective Date (mm/dd/yyyy)
Page 2 of 3
CONFIDENTIALITY AGREEMENT
Examples of Breaches of Confidentiality (What you should NOT do.)
These are examples only and do not include all possible breaches of confidentiality.
- Unauthorized reading of patient account information.
- Unauthorized reading of a patient's chart.
- Unauthorized access to my own medical information if my job duties do not authorize me to have access to electronic
medical records (for example, KP HealthConnect).
- Accessing medical information of friends, co-workers, family members, or anyone else, unless it is required for my job.
- Discussing confidential information in a public area such as a waiting room or elevator.
- Discussing or otherwise sharing confidential information with anyone in your personal life, including family members or
friends.
- Accessing records for any reason other than for legitimate business purpose.
- Accessing records of family, friends, co-workers, patients in the media, well known political figures, celebrities, or anyone
else about whom you are curious.
- Sending confidential information to your personal e-mail account, unless you are authorized to do so and the information is
transmitted in accordance with required procedures (e.g., encrypted).
- Saving confidential electronic information to a KP-owned or non-KP-owned flash drive, CD, or any other removable or
transportable storage device unless you first secure permission as outlined in the Secure Electronic Storage provisions of
the KP Information Security Policy.
- Saving confidential electronic information to a KP-owned or non-KP-owned workstation, laptop computer, personal digital
assistant, or any other mobile computing device unless you first secure permission as outlined in the Secure Electronic
Storage provisions of the KP Information Security Policy.
- Using personal devices (digital cameras, camera phones) to take photographs that may include confidential information as
the primary subject or in the background.
- Documenting or referencing confidential information on any social networking site, such as Twitter, My Space.
- Telling a co-worker your password so that he or she can login to your work.
- Telling an unauthorized person the access codes for employee files or patient accounts.
- Being away from your workstation while you are logged into an application, without locking your system to protect
confidential information.
- Unauthorized use of a co-worker's password to logon to a Kaiser Permanente information system.
- Unauthorized use of a user ID to access employee files or patient accounts.
- Allowing a co-worker to use your secured application* for which he/she does not have access after you have logged in.
* secured application = any computer program that allows access to confidential information. A secured application usually requires a user
name and password to log in.
AGREEMENT - (Continued)
Page 2 of 3
HR Service Center
Fax to: (877) 477-2329
Telephone: (877) 457-4772
Executives: Contact your Executive Benefits Specialist
< Previous Page
2870 NCAL 01/26/2012 15
2870
SIGNATURE (Required if not submitted online)
* Date (mm/dd/yyyy)
* Employee Signature
After completing the form:
1. Print form to keep a copy for your records.
2. Print another copy and sign it for your supervisor.
3. Press the Submit button.
4. Wait for a pop-up screen to confirm the form has been submitted. (This may take a few minutes.)
5. Submit online or fax your form to HR Service Center (877) 477-2329 or interoffice mail to HR Service Center,
Alameda.
* First Name Middle Name * Last Name
* Employee ID
* Work Phone Number (###)###-####
* Effective Date (mm/dd/yyyy)
Page 3 of 3
CONFIDENTIALITY AGREEMENT
12. I understand that I am responsible for my access, use, or misuse of confidential information and know that my access to
confidential information may be audited.
13. I understand that my supervisor/chief of service or other managers and/or the Compliance Hot Line are available if I think
someone is misusing confidential information or is misusing my password. I further understand that Kaiser Permanente will not
tolerate any retaliation because I make such a report.
14. I understand that patient privacy and security is included in various training programs within Kaiser Permanente (for example:
New Employee training, Annual Compliance Training), and by taking such training, I understand the obligations of confidentiality. I
further understand that it is my responsibility to secure guidance from my supervisor or manager in the event any questions exist
relating to my obligations regarding confidentiality.
15. I understand that this policy is not meant to prohibit any protected rights provided for in the National Labor Relations Act (for
represented employees).
16. I understand that failure to comply with this agreement may result in disciplinary action up to and including termination of
employment or other relationship with Kaiser Permanente. I understand that I may also be subject to other remedies allowed by
law.
17. I understand that I must also comply with any laws, regulations, and other Kaiser Permanente policies, including the Principles of
Responsibility that address confidentiality.
18. By signing (or selecting the submit button below), I agree that I have read, understand, and that I will comply with this
Confidentiality Agreement.
AGREEMENT - (Continued)
Page 3 of 3
HR Service Center
Fax to: (877) 477-2329
Telephone: (877) 457-4772
Executives: Contact your Executive Benefits Specialist
Submit
< Previous Page
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Form 2870: CONFIDENTIALITY AGREEMENT

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Completed 4 March 2021

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