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Appendix C. Confidentiality Statement

Developing a Community-Based Patient Safety Advisory Council

Appendix C. Confidentiality Statement


Patient advisory council members must sign confidentiality statements as part of their membership processing. A sample follows.


A federal law called "HIPAA" (Health Insurance Portability and Accountability Act) defines "protected health information" and sets standards for health care providers to protect that information. The law also defines stiff penalties (fines and even imprisonment) for violating those privacy provisions. Various State laws also protect the privacy of patient information.

Protected health information includes any information regarding a patient's visit at any Aurora Health Care facility. That information includes, but is not limited to, name, address, phone number, date of birth, financial information, diagnosis, and treatment information.

In addition to defining protected health information, the law requires that we must define the minimum necessary information which employees, volunteers, contracted agencies, and other individuals can have access to. As a non-employed committee member, you may have access to protected health information. It is important that you recognize that any protected health information can only be used and disclosed as permitted by law. For example, this information cannot be shared by written, verbal, or E-mail communication at school or home; with friends or family; or outside the hospital, clinic, or other health care facility unless specifically permitted by law.

The easiest way to remember how to implement this law is the saying, "What you see or hear here, must remain here." We require your cooperation in following these rules.

Please sign below that you have reviewed this information, understand it, and agree to it.

Thank you.

I have reviewed the information above, understand it, and agree to abide by it.

Name (please print) ________________________________________________

Signature ________________________________________________________

Date ____________________________________________________________

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Current as of April 2008
Internet Citation: Appendix C. Confidentiality Statement: Developing a Community-Based Patient Safety Advisory Council. April 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/patient-safety-advisory-council/appendix-c.html