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Application Form

I understand that Loyalty Group has a legal and ethical responsibility to safeguard the privacy of all its patients and to protect the confidentiality of patient health information. In the course of my assignment through Loyalty Group. I understand that I may have access t receive or possess patient health information. I further understand that I must sign and comply with this confidentiality agreement in order to get authorization for access to any patient health information and that this signed copy will be placed in my employee record.


I hereby agree that I will abide by the following;


  1. Except as required by law, I will not disclose patient health information to anyone (including family members and friends), who are not authorized to have to the information. I will not use or disclose any patient health information in an authorized, improper or illegal manner, including selling any patient health information. I understand that any computer password assigned to me by Loyalty Group and used to access Loyalty Group computer systems implicated my responsibility to preserve the confidentiality of patient health information.

  2. I will not directly or indirectly, access, seek access to, view, destroy, use or disclose any patient health information other that what is required for me to do work and in accordance with Loyalty Group Policies and procedures.

  3. I will make every effort not to discuss patient health information in any areas where persons not entitled to the information may overhear a conversation and obtain the information.

  4. I will not make inquiries about patient health information for other personnel who do not have authorization to access such information.

  5. I will not disclose my computer password or knowingly use another person’s computer password instead of my own for any reason. I agree that I will handle my computer password with care.

  6. I will not make any unauthorized transmissions, inquiries, modifications or purging to patient health information in Loyalty Group computer system. Such unauthorized transmissions shall include, but shall not be limited to, removed and/or transferring patient health information for Loyalty Group computer system to unauthorized location or computers.

  7. I understand that all computer access activity in subject to audit and monitoring.

  8. I will log off any computer prior to leaving I unattended for more than a brief period of time.

  9. I will comply with all Loyalty Group privacy and security policies and procedures pertaining to the protection of patient health information.

  10. I will immediately report any activity by any person including myself, that is a violation of this agreement or any of Loyalty Group privacy or security policies.

  11. Upon completion or termination of my assignment or contract, I agree to immediately return Loyalty Group documents or other media containing patient health information in my possession.

  12. My obligations as set forth in this agreement will continue after my termination of employment. I understand that violation of this Agreement my result in disciplinary action, up and including termination, as well as legally liability.


I have read the above, and I understand and agree to comply with all its terms.

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