West Tennessee Healthcare
HIPAA DE-IDENTIFIED CERTIFICATION FORM
Definitions. As used in this Agreement, and unless otherwise specified to the contrary, the following term
shall have the meaning ascribed herein below:
Information” as such term is used in this Attachment shall mean: (i) “Protected Health
Information” and “Individually Identifiable Health Information” as those terms are defined in
HIPAA; and (ii) any information, whether oral or recorded in any form or medium, that relates to
any present, past, or future patient of Covered Entity or any of its affiliates or subsidiaries; and
(iii) all data and information of any kind, whether oral or recorded in any form or medium, that
originates with Covered Entity or any of its affiliates or subsidiaries; and (iv) all data and
information, whether oral or recorded in any form or medium, that relates to Covered Entity or
that constitutes proprietary information of Covered Entity, including, without limitation, patient
information, financial and administrative information, payor information, medical staff
information, methods, systems, or practices of Covered Entity, and computer program
information.
In the course of volunteering at Jackson-Madison County General Hospital, students may come into contact
with Information even though they may not be directly involved with patient care. Such Information must
be maintained in the strictest confidence. However, if Information is to be used in course work after the
fact, the Information must be de-identified, thereby making it exempt from HIPAA requirements. To de-
identify Information under the Privacy Standards (CFR §164.514, §164.502(d)), the following 18
identifiers must be removed regarding the individual, relatives, employers, or household members:
1. Names
2. All geographic subdivisions smaller than a state, including street address, city, county, precinct,
zip code and equivalent geocodes, except for the initial three digits of a zip code if, according to
current Census data,
the geographic unit formed by combining all zip codes with the same three initial digits
contains more than 20,000 people, and
the initial three digits of a zip code for all geographic units containing 20,000 or fewer people
is changed to 000
3. All elements of dates (except year)for dates directly related to an individual, including birth date,
admission date, discharge date, date of death, and all ages over 89 and all elements of dates
(including year) indicative of such age, except that such ages and elements may be aggregated into
a single category of age 90 or older
4. Telephone numbers
5. Fax numbers
6. Electronic mail addresses
7. Social security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers, including license plate numbers
13. Device identifiers and serial numbers
14. Web Universal Resource Locators (URLs)
15. Internet Protocol (IP) address numbers
16. Biometric identifiers, including finger and voice prints
17. Full face photographic images and any comparable images
18. Any other unique identifying number, characteristic or code, unless the regulations explicitly
permit retention or re-identification.
I certify that the Information received or reviewed for any course work does not include any of the 18
identifiers listed above. I understand that violation of this agreement may result in corrective and/or civil
action.
___________________________________________ _______________________________
Signature of Student or Volunteer Date
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