Termination Nondisclosure Agreement for Employees/Students/Volunteers

[Name of healthcare provider] has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of my employment/assignment at [name of healthcare provider], I may have come into possession of or overheard confidential patient information, even though I may not have been directly involved in providing patient services.

I understand that such information must be maintained in the strictest confidence. I hereby agree that I will not at any time after my employment/assignment with [name of healthcare provider] disclose any patient information, in any form, to any person whatsoever.

I understand that violation of this agreement may result in civil action.

________________________________        ________________________________
Signature of Employee/Student/Volunteer             Witness

______________________________________
Date

Note: This sample form was developed for AHIMA for discussion purposes. It should not be used without review by your organization’s legal counsel to ensure compliance with local and state laws.


Source: AHIMA Practice Brief, Journal of AHIMA 74, no.6 (2003), 64C.