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Annual Forms: Confidentiality Agreement

All Volunteers are required to have certain documentation updated annually. For your convenience, below is the Confidentiality Agreement. To complete the form, please read, provide your signature, and click submit. Thank you!


    I shall respect the privacy of patients and families and hold in confidence all information obtained in the course of professional services. Therefore, I will not disclose confidential information to anyone, except: (1) in the process of coordinating care (such as to the Hospice Interdisciplinary Team Members and other health care professionals involved in the patient’s or family members’ care); (2) as legally mandated; (3) in order to facilitate Hospice operations including efforts to obtain payment for services, quality improvement initiatives, training, etc. (4) if there is a valid authorization to release information for specific purposes. I have reviewed Hospice’s policy on privacy and security and electronic communications and Hospice of the Piedmont’s notice of privacy practices and have had the opportunity to clarify any questions that I might have. I shall be responsible to store or dispose of patient/family records in ways that maintain confidentiality. I will be responsible for protecting all confidential information including verbal, written and electronic forms. I understand that it is my responsibility to report immediately any breach, potential breach or suspected breach to my supervisor or a member of the management team of Hospice of the Piedmont. I, upon termination of employment or my volunteer position with Hospice shall maintain patient/family confidentiality. I understand that I will be subject to disciplinary action up to an including termination of employment should I violate these policies or this agreement.
  • Section to be completed by Volunteer Coordinator: