HIPAA COMPLIANCE SIGNATURE FORM
Staff (full name, print):
Date:
My Commitment to Compliance:
I have read and understand our HIPAA Compliance manual. I agree to do all I can, within my area of responsibility, to maintain up-to-date knowledge about federal and state laws and program requirements. I will comply with these requirements to the best of my ability, and to
immediately let the Compliance Officer know if there is any area where I feel our office is not in Compliance with these laws and program requirements. Our policy is a simple, yet powerful four-step process: Keep up-to-date, educate, comply, and audit/correct.
a. We seek to maintain up-to-date knowledge about federal and state law pertaining to protection of our patients Protected Health Information.
b. We educate our staff and keep them up-to-date about federal and state law as it applies to Protected Health Information.
c. Our policy is to comply with all federal and state law governing Protected Health
Information.
We desire that all our staff are particularly cognizant of the fact that protected health
information must be treated with utmost attention, accuracy, honesty, and integrity. We seek to educate and carry out these policies with all our interns, employees, managers, clinicians, and where appropriate, contractors and other agents.
I agree with our policy and will do all I can to comply with all regulatory laws pertaining to personal health information. I understand that our office has an open-door policy and I may discuss any problems I feel may occur with PHI without worry of recourse with my supervisor or other supervisors.
Signature of Staff
Signature of Compliance Officer
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