CONFIDENTIALITY AGREEMENT BETWEEN MEDICAL PRACTICE & FILE
STORAGE FACILITY
The file storage facility named below hereby agrees that it accepts
for storage patient files provided by the medical practice described
below.
The file storage facility agrees that it will not allow its representatives,
agents or employees to read, use or disclose any patient information
contained within the files provided to it.
The file storage facility agrees that it will maintain complete
confidentiality with respect to all patient information (whether
received or created before or after the date of this agreement).
The file storage facility agrees that, upon receiving a request
from the medical practice, it will deliver the requested files
to the medical practice on a timely basis.
The file storage facility represents that it has safeguards in
place, to protect the security of patient information.
The file storage facility represents that it is aware of and
fully compliant with Saskatchewan’s Health Information Protection
Act
The file storage facility acknowledges and agrees that any breach
of this agreement may result in termination of the service agreement
and may be grounds for legal action by the medical practice against
the service provider.
File Storage Facility: (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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