Site Visitor Confidentiality Agreement
I, ______________________, participate in the accrediting process of the American Psychological Association ("APA"), Commission on Accreditation ("CoA"), as a site visitor. In order to carry out my duties and responsibilities as a site visitor, I understand that, while a site visitor at a program ("Program"), I may come in contact with certain patient/client information that is confidential in nature, including information that can be used to identify those patients/clients ("confidential information"). In most instances, this confidential information is protected health information covered by the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). For purposes of this Confidentiality Agreement, this confidential information includes all health information protected by state law and/or HIPAA that is transmitted or maintained in any form, including written, oral, or electronic, whether such information is purposefully or incidentally disclosed to me by any party (hereafter "PHI").
Therefore, in exchange for my participation in the accreditation process, I hereby acknowledge and agree to the following:
- During the accreditation review process, I may come in contact with PHI either as part of the function of my duties or incidentally.
- I agree that I will not use any PHI except to carry out my duties and responsibilities as a site visitor during the accreditation process in accordance with CoA's established policies, procedures, and requirements.
- I agree that I will not further disclose any PHI except as specifically requested by APA for accreditation purposes, or as required by law.
- I agree that I will not make a duplicate copy of, or by any other means record, any PHI.
- I agree to use reasonable and appropriate safeguards to prevent any use and disclosure of PHI other than as permitted by this Confidentiality Agreement.
- I agree to the extent practicable to mitigate any harmful effect known to me of a use or disclosure of PHI in violation of this Confidentiality Agreement.
- Finally, I agree to immediately notify the Office of Program Consultation and Accreditation at APA and the Program of any use or disclosure of PHI not permitted by this Confidentiality Agreement of which I become aware.
Signed this _____ day of _______ 20__.
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Signature
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Printed Name
