CONFIDENTIALITY AGREEMENT BETWEEN MEDICAL PRACTICE & FILE DESTRUCTION FACILITY

The Contractor named below hereby agrees that it will destroy patient files and other confidential information provided by the medical practice described below.

The Agreement

The Contractor agrees that it will, with respect to all documents provided by the medical practice to it for destruction:

a) Shred all documents within 10 days of taking possession of those documents;
b) Not permit any agent or employee of the Contractor, or any other person, to read or copy any document;
c) Maintain all documents in a secure location until they are shredded;
d) Shred the documents in such a manner that they cannot be reconstructed;
e) Comply with all the requirements of The Health Information Protection Act and the regulations under The Health Information Protection Act respecting personal health information.

The Contractor acknowledges and agrees that any breach of this agreement may result in termination of the agreement for destruction of documents.

Contractor: (please print) ____________________________________________________________

Authorized Signatory: (please print) _______________________________________________________

X______________________________________ _________________________________________
                    Authorized Signature                                         Date (dd/mm/yy)

Medical practice:____________________________________________________________

Witness (privacy officer): (please print) Dr________________________________________________

X______________________________________ _________________________________________
                     Witness Signature                                             Date (dd/mm/yy)

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