Compliance Committee Confidentiality Agreement
I understand and agree that, in connection with the performance of my duties as a member of the Compliance Oversight Committee, I will be engaged in activities of a confidential nature, including but not limited to participating in reviews and evaluations of internal examinations, evaluations and self-evaluations of the policies, practices and procedures of this organization. I further understand that, in this capacity, I will be expected to receive and/or to become privy to information of a confidential nature, including, but not limited to, medical records, documents and statistics which go to the issue of physician compliance with policies, procedures, statutes and regulations, and other information of a confidential nature. I further understand that I will be called upon to evaluate such information, in part, by the application of laws, regulations and policies, as well as policies of this organization, to the information which I receive. I understand that my position as a member of this Committee is one which demands the highest trust, and that the organization’s policies and procedures, as well as, in some instances, specific statutes, regulations and governmental policies, protect the confidentiality of certain records and information which I will be reviewing by prohibiting their disclosure in any manner. In addition to any duty of confidentiality or non-disclosure imposed on me by specific statutes, regulations and governmental policies, I agree to keep secret, and not to disclose to others nor make any personal use of whatsoever, either during my service on said Committee or at any time thereafter, of any said confidential information, and to hold any such documents and/or information, regardless of their nature, in strictest confidence. I understand that any violation of this confidentiality statement will subject me to disciplinary action, up to and including removal from this Committee and/or termination of employment. I further understand that my duty to maintain the information in confidence imposed hereunder shall survive my resignation or termination from this Committee or my termination of employment for whatever reason from this organization.
Signature / Date
Printed Name / Title
Witness Signature / Date