HIPPA Policy Acknowledgement Form
As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all employees are trained regarding the privacy policies at Lexington Clinic.
HIPAA defines the type of information that must be kept confidential as “Protected Health Information” or PHI. PHI is any and all information about an individual’s physical or mental health that identifies the individual, or there is reason to believe the information could identify them. This includes any type of information found in medical and billing records such as office notes, lab and x-ray reports, diagnoses, and so forth.
PHI includes demographic information such as name, address, phone and fax numbers, e-mail addresses, date of birth, Social Security numbers, photographs, relative names, etc. PHI also includes any information that may identify an individual—for example, job titles, community positions, etc. PHI can be in any form—written, verbal, and electronic.
Any information that you see, hear or say must be kept confidential and used only for specific purposes related to a patient’s treatment, payment, or to the operations of Lexington Clinic. This information is to also remain confidential following the completion of your assignment at Lexington Clinic. Please click to review the ‘Safeguards to Protect the Privacy of Protected Health Information at Lexington Clinic’ before signing the form.
Questions related to HIPAA, either your own or from patients, should be directed to the supervisor/manager of the department, or you can call the Director of Medical Records at 1-859-258-4177 or the Compliance Officer at 1-859-258-6069. If you would like to report a HIPAA concern anonymously, call 1-859-258-4833 or 1-877-851-2562.
I understand that patient information is to remain confidential and I agree not to disclose confidential patient information as defined by HIPAA during my placement at Lexington Clinic except for the purposes of treatment, payment and health care operations. I also acknowledge that PHI is to remain confidential following my placement at Lexington Clinic. I have received and agree to follow the “Safeguards to Protect the Privacy of Protected Health Information at Lexington Clinic.’