Sample Privacy Forms

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Confidentiality Agreement for Employees
· applies to all clinic employees
Confidentiality Agreement between Medical Practice and Service Provider
· applies to third parties that may have access to patient information (e.g. offsite dictation, billing software companies, etc.)
Confidentiality Agreement between Medical Practice and File Storage Facility
· applies to third party physical storage facilities for paper charts, electronic backup tapes, etc.
Confidentiality Agreement between Medical Practice and File Destruction Facility
Request for Access to Personal Information
· applies to patient requests for information or requests from patient’s legal representative
Request to Amend Personal Information
· applies to patient requests for amendments or requests originating from patients’ legal representatives.