Nondisclosure Statement
I acknowledge that I will be provided access to information, systems, operations, or procedures that are
security sensitive or have been identified as confidential by the Ohio Department of Aging (ODA), the
State of Ohio, or the United States of America. Each person authorized to access ODA and its business
partner’s systems holds a position of trust relative to this information and must recognize the necessity to
keep this information confidential and secure. As such, I agree to the following:
• I will only use an email address that is my personal email address, not a group or shared email;
• That my access to this information is provided solely in my capacity and solely for the purposes
relative to my capacity as a provider of waiver services;
• That unauthorized disclosure or use of this information will irreparably harm the interests of
ODA and its business partners and the State of Ohio and may constitute a violation of state and
federal law;
• That the information may represent confidential personal information, protected health
information, or proprietary information, the release or disclosure of which may be restricted or
prohibited by state and federal law;
• That I shall regard all such information as confidential and that I shall not disclose, reveal,
communicate, impart, or divulge the information or any summary or synopsis of the information
in any manner or any form whatsoever;
• That ODA and its business partners has instituted security measures designed to identify attempts
to tamper with the websites, systems, operations, or procedures and that information collected
through theses security measures may be used in connection with a criminal prosecution or other
legal proceedings;
• That ODA and its business partners has instituted security measures designed to monitor and
detect the unauthorized access or attempt to access information and that these security measures
may result in the collection of information that may be used in connection with a criminal
prosecution or other legal proceedings;
• That violation of any of these provisions may result in the cancellation of my security access and
referral to the appropriate enforcement authorities.
By signing this statement, I acknowledge that I understand and agree to adhere to the limitations
on access and disclosure described above.
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Signature Date
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Printed Name
