Body Art Confidentiality Statement Template

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Confidentiality Statement
I, the undersigned, understand and agree to abide by the following in order to ensure that all records
and data pertaining to the client are kept confidential.
Furthermore, I understand that violation of this confidentiality statement is subject to appropriate
disciplinary action(s) on the part of the body art facility that could include being discharged from my
position and/or being subject to civil and possible criminal penalties brought against me. By
initialing the following statements, I further agree that:
______Reports, records or information cannot be released except to appropriate authorities (state or
local health department officials, etc.).
______Any document to be disposed of that contains patients identifiers shall be destroyed
according
to Section 12.5 of the “Requirements for Body Art Facilities.”
All confidential records shall be kept according to Section 12.2 of the “Requirements for
Body
Art Facilities.”
______I will not receive visitors when confidential information is out or visible.
______I will not disclose/give my computer password or office keys to unauthorized persons.
______Data generated and records used by the contracted/ employee remains the property of the
body art facility and not the individual contractor/ employee.
______I will not discuss any identifying client information without the client’s knowledge and
approval, except in the performance of job-related contract duties.
______Knowledge of someone's medical status is to be treated confidentially and is not to be shared
with persons outside of the body art facility or with contracted or co-workers unless they
have the need to know in order to prevent disease transmission.
Infringement of these rules will be documented.
Contractor/Employee Signature: _________________________________________________
Date: ___________________________
Owner/Manager Signature:_____________________________________________________
Date: ___________________________
Oath.wpd (6/02)
Confidentiality Statement
I, the undersigned, understand and agree to abide by the following in order to ensure that all records
and data pertaining to the client are kept confidential.
Furthermore, I understand that violation of this confidentiality statement is subject to appropriate
disciplinary action(s) on the part of the body art facility that could include being discharged from my
position and/or being subject to civil and possible criminal penalties brought against me. By
initialing the following statements, I further agree that:
______Reports, records or information cannot be released except to appropriate authorities (state or
local health department officials, etc.).
______Any document to be disposed of that contains patients identifiers shall be destroyed
according
to Section 12.5 of the “Requirements for Body Art Facilities.”
All confidential records shall be kept according to Section 12.2 of the “Requirements for
Body
Art Facilities.”
______I will not receive visitors when confidential information is out or visible.
______I will not disclose/give my computer password or office keys to unauthorized persons.
______Data generated and records used by the contracted/ employee remains the property of the
body art facility and not the individual contractor/ employee.
______I will not discuss any identifying client information without the client’s knowledge and
approval, except in the performance of job-related contract duties.
______Knowledge of someone's medical status is to be treated confidentially and is not to be shared
with persons outside of the body art facility or with contracted or co-workers unless they
have the need to know in order to prevent disease transmission.
Infringement of these rules will be documented.
Contractor/Employee Signature: _________________________________________________
Date: ___________________________
Owner/Manager Signature:_____________________________________________________
Date: ___________________________
Oath.wpd (6/02)

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