Form CDPH 8720 Agreement by Employee/Contractor to Comply With Confidentiality Requirements - California

Form CDPH8720 or the "Agreement By Employee/contractor To Comply With Confidentiality Requirements" is a form issued by the California Department of Public Health.

The form was last revised in July 1, 2017 and is available for digital filing. Download an up-to-date Form CDPH8720 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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State of California
Health and Human Services Agency
California Department of Public Health
Agreement by Employee/Contractor to Comply with Confidentiality Requirements
Summary of Statutes Pertaining to Confidential Public Health Records and Penalties for Disclosure
All HIV/AIDS case reports and any information collected or maintained in the course of surveillance-
related activities that may directly or indirectly identify an individual are considered confidential public
health record(s) under California Health and Safety Code (HSC), Section 121035(c) and must be
handled with the utmost confidentiality. Furthermore, HSC §121025(a) prohibits the disclosure of
HIV/AIDS-related public health records that contain any personally identifying information to any third
party, unless authorized by law for public health purposes, or by the written consent of the individual
identified in the record or his/her guardian/conservator. Except as permitted by law, any person who
negligently discloses information contained in a confidential public health record to a third party is
subject to a civil penalty of up to $5,000 plus court costs, as provided in HSC §121025(e)(1). Any
person who willfully or maliciously discloses the content of a public health record, except as
authorized by law, is subject to a civil penalty of $5,000-$25,000 plus court costs as provided by HSC
§121025(e)(2). Any willful, malicious, or negligent disclosure of information contained in a public
health record in violation of state law that results in economic, bodily, or psychological harm to the
person named in the record is a misdemeanor, punishable by imprisonment for a period of up to one
year and/or a fine of up to $25,000 plus court costs (HSC §121025(e)(3)). Any person who is guilty of
a confidentiality infringement of the foregoing type may be sued by the injured party and shall be
personally liable for all actual damages incurred for economic, bodily, or psychological harm as a
result of the breach (HSC §121025(e)(4)). Each disclosure in violation of California law is a separate,
actionable offense (HSC §121025(e)(5)).
Because an assurance of case confidentiality is the foremost concern of the California Department of
Public Health, Office of AIDS (CDPH/OA), any actual or potential breach of confidentiality shall be
immediately reported. In the event of any suspected breach, staff shall immediately notify the director
or supervisor of the local health department’s HIV/AIDS surveillance unit who in turn shall notify the
CDPH/OA Surveillance Section Chief or designee. CDPH/OA, in conjunction with the local health
department and the local health officer shall promptly investigate the suspected breach. Any evidence
of an actual breach shall be reported to the law enforcement agency that has jurisdiction.
CDPH 8720 (07/17)
Page 1 of 2
State of California
Health and Human Services Agency
California Department of Public Health
Agreement by Employee/Contractor to Comply with Confidentiality Requirements
Summary of Statutes Pertaining to Confidential Public Health Records and Penalties for Disclosure
All HIV/AIDS case reports and any information collected or maintained in the course of surveillance-
related activities that may directly or indirectly identify an individual are considered confidential public
health record(s) under California Health and Safety Code (HSC), Section 121035(c) and must be
handled with the utmost confidentiality. Furthermore, HSC §121025(a) prohibits the disclosure of
HIV/AIDS-related public health records that contain any personally identifying information to any third
party, unless authorized by law for public health purposes, or by the written consent of the individual
identified in the record or his/her guardian/conservator. Except as permitted by law, any person who
negligently discloses information contained in a confidential public health record to a third party is
subject to a civil penalty of up to $5,000 plus court costs, as provided in HSC §121025(e)(1). Any
person who willfully or maliciously discloses the content of a public health record, except as
authorized by law, is subject to a civil penalty of $5,000-$25,000 plus court costs as provided by HSC
§121025(e)(2). Any willful, malicious, or negligent disclosure of information contained in a public
health record in violation of state law that results in economic, bodily, or psychological harm to the
person named in the record is a misdemeanor, punishable by imprisonment for a period of up to one
year and/or a fine of up to $25,000 plus court costs (HSC §121025(e)(3)). Any person who is guilty of
a confidentiality infringement of the foregoing type may be sued by the injured party and shall be
personally liable for all actual damages incurred for economic, bodily, or psychological harm as a
result of the breach (HSC §121025(e)(4)). Each disclosure in violation of California law is a separate,
actionable offense (HSC §121025(e)(5)).
Because an assurance of case confidentiality is the foremost concern of the California Department of
Public Health, Office of AIDS (CDPH/OA), any actual or potential breach of confidentiality shall be
immediately reported. In the event of any suspected breach, staff shall immediately notify the director
or supervisor of the local health department’s HIV/AIDS surveillance unit who in turn shall notify the
CDPH/OA Surveillance Section Chief or designee. CDPH/OA, in conjunction with the local health
department and the local health officer shall promptly investigate the suspected breach. Any evidence
of an actual breach shall be reported to the law enforcement agency that has jurisdiction.
CDPH 8720 (07/17)
Page 1 of 2
Employee Confidentiality Pledge
I recognize that in carrying out my assigned duties, I may obtain access to private information about
persons diagnosed with HIV or AIDS that was provided under an assurance of confidentiality. I
understand that I am prohibited from disclosing or otherwise releasing any personally identifying
information, either directly or indirectly, about any individual named in any HIV/AIDS confidential
public health record. Should I be responsible for any breach of confidentiality, I understand that civil
and/or criminal penalties may be brought against me. I acknowledge that my responsibility to ensure
the privacy of protected health information contained in any electronic records, paper documents, or
verbal communications to which I may gain access shall not expire, even after my employment or
affiliation with the Department has terminated.
By my signature, I acknowledge that I have read, understand, and agree to comply with the terms and
conditions above.
Employee name (print)
Employee Signature
Date
Supervisor name (print)
Supervisor Signature
Date
Name of Employer
PLEASE RETAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS
CDPH 8720 (07/17)
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Download Form CDPH 8720 Agreement by Employee/Contractor to Comply With Confidentiality Requirements - California

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