DOEA Form 181 "Employee Statement of Understanding of Privacy Policies" - Florida

What Is DOEA Form 181?

This is a legal form that was released by the Florida Department of Elder Affairs - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOEA Form 181 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 181 "Employee Statement of Understanding of Privacy Policies" - Florida

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Employee Statement of Understanding of Privacy Policies
Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
(850) 414-2000
I, __________________________________________, have been trained and informed about
the business and privacy practices in affect at
as a result of the Health Insurance
DOEA
Portability and Accountability Act (HIPAA).
I understand that I am responsible for ensuring the security, integrity and confidentiality of patient
health information created, obtained and/or maintained by
.
DOEA
I have reviewed, understand, and agree to abide by the following Privacy Policies:
I.
CONSUMER'S PRIVACY RIGHTS POLICY
II.
NOTICE OF PRIVACY PRACTICES
III.
BUSINESS ASSOCIATES
IV.
RESPONSIBILITIES OF COVERED ENTITIES.
V.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
VI.
DISCLOSURE TRACKING POLICY
VII.
MINIMUM NECESSARY REQUIREMENTS
VIII. INDIVIDUAL RIGHTS TO PROTECTED HEALTH INFORMATION
IX.
ADMINISTRATIVE REQUIREMENTS STANDARDS
X.
DOEA GENERAL INFORMATION SYSTEMS ACCESS POLICY
XI.
CHANGES TO POLICIES & PROCEDURE
XII.
COMPLAINTS
I understand that non-compliance will be cause for disciplinary action up to and including
dismissal from
, and possible legal actions for violations of applicable regulations and laws.
DOEA
I agree to promptly report all violations or suspected violations of any of the above policies to
's Privacy Officer through the designated reporting channels.
DOEA
____________________________________________________________________
Print Employee Name
___________________________________________________ ________________
Employee Signature
Date
___________________________________________________ ________________
Signature
Date
DOEA
DOEA Form 181 (04/03)
Page 1 of 1
Employee Statement of Understanding of Privacy Policies
Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
(850) 414-2000
I, __________________________________________, have been trained and informed about
the business and privacy practices in affect at
as a result of the Health Insurance
DOEA
Portability and Accountability Act (HIPAA).
I understand that I am responsible for ensuring the security, integrity and confidentiality of patient
health information created, obtained and/or maintained by
.
DOEA
I have reviewed, understand, and agree to abide by the following Privacy Policies:
I.
CONSUMER'S PRIVACY RIGHTS POLICY
II.
NOTICE OF PRIVACY PRACTICES
III.
BUSINESS ASSOCIATES
IV.
RESPONSIBILITIES OF COVERED ENTITIES.
V.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
VI.
DISCLOSURE TRACKING POLICY
VII.
MINIMUM NECESSARY REQUIREMENTS
VIII. INDIVIDUAL RIGHTS TO PROTECTED HEALTH INFORMATION
IX.
ADMINISTRATIVE REQUIREMENTS STANDARDS
X.
DOEA GENERAL INFORMATION SYSTEMS ACCESS POLICY
XI.
CHANGES TO POLICIES & PROCEDURE
XII.
COMPLAINTS
I understand that non-compliance will be cause for disciplinary action up to and including
dismissal from
, and possible legal actions for violations of applicable regulations and laws.
DOEA
I agree to promptly report all violations or suspected violations of any of the above policies to
's Privacy Officer through the designated reporting channels.
DOEA
____________________________________________________________________
Print Employee Name
___________________________________________________ ________________
Employee Signature
Date
___________________________________________________ ________________
Signature
Date
DOEA
DOEA Form 181 (04/03)
Page 1 of 1