Protected Health Information includes, but is not limited to, medical records relating to a patient’s past, present and future care and treatment as well as billing records related to that care which contains any of the following identifiers:
Street addresses, city, county, zip code
Telephone / fax numbers
Social Security numbers
Medical Records numbers
Health plan beneficiary numbers
All elements of dates related to an individual
Certificate / license numbers
Vehicle identifiers / serial numbers
Device identifiers / serial numbers
Internet protocol address number
Finger / voice prints
Full face photo image
Any other unique identifying number, characteristic or code.
During the course of the job shadow experience, students may see, overhear, access or temporarily possess a patient’s Protected Health Information.
All protected health information must be maintained in the strictest confidence. As a condition of participation in the Job Shadow Program at SSM Health Care – St. Louis, all students must sign a Confidentiality Agreement. Any violation of this agreement may result in civil and/or criminal penalties under federal and state law.
Confidentiality Agreement for Non-Employees
If you are 18 years of age or under, your parent or legal guardian must also read and acknowledge this form.
I, the undersigned, acknowledge that during the course of my voluntary participation or performance of duties at SSM Health Care – St. Louis that I may receive access to confidential information of SSM Health Care that is prohibited from disclosure to others.
“Confidential Information” means information provided by SSM Health Care that is not commonly available to the general public, or is required by law or regulation to be protected from disclosure to third parties not considered part of the organization’s “workforce” as that term is defined by federal and state health information privacy regulations such as the Health Information Portability and Accountability Act. Confidential Information includes, but is not limited to, information contained in patient medical records and any other health information which identifies a patient; quality assurance, research or peer review information; and information concerning SSM Health Care employees, services or business operations. Such information can be acquired by any means and in any form, written, spoken or electronic.
I agree not to share, disclose or discuss Confidential Information with anyone who does not have a legitimate interest in such information. I will abide by SSM Health Care’s policies and procedures concerning the use or disclosure of Confidential Information and I will contact a SSM Health Care representative if I have any questions regarding these policies and procedures.
I will maintain and protect the privacy of SSM Health Care’s employees, medical staff and patients in my use and disclosure of Confidential Information and I will not misuse or be careless with such information.
I understand that any violation of this agreement or SSM Health Care’s policies related to access, use of disclosure of Confidential Information may result in significant legal ramifications for which I will be held solely responsible with respect to this agreement.
I acknowledge that I have reviewed all of the information above. I understand that compliance with the principles, policies and procedures expressed above is a condition of my participation and continued presence at SSM Health Care.
If you are completing the job shadow online application, please close this window and complete the confidentiality section of the form.