HFHT Staff and Practice Staff Annual Privacy Pledge Form

Please complete and submit the form below. Your privacy training is not considered complete unless this form is submitted. 

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I am a.. *

• HFHT Employee
• Physician/Practice Staff Member
• Student
• Volunteer

Practice Name (if you are a Practice Staff Member)

Email address of Practice Manager (if you are a Practice Staff Member)

First and Last Name: *

Which privacy training session did you complete? *

• HFHT Refresher Privacy Training (short video).
• HFHT Privacy Training Webinar (2 hours).

Date you attended training *

Email address (to send you a privacy training confirmation): *

Email

Confirm Email

Privacy Pledge

I have taken HFHT privacy training and understand the information provided and my privacy responsibilities. Specifically, I understand that any information (written, verbal, or other form) obtained during the performance of my duties must remain confidential. This includes all information about patients, clients, families, employees, and medical staff, as well as any information otherwise marked or known to be confidential. I understand that any unauthorized release or carelessness in the handling of confidential information is considered a breach of my duty to maintain confidentiality. I further understand that any breach of my duty to maintain confidentiality could be grounds for disciplinary action up to and including immediate dismissal.

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Privacy Pledge

I have taken HFHT’s privacy training and understand the information provided and my privacy obligations. Further, I am committed to HFHT’s privacy policies and procedures. I understand my responsibilities as a Health Information Custodian for my patients and the staff working in my office.

I have read and commit to the privacy pledge. *

• Confirm

Submit