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Application Form

Agreement by contractor to comply with HIV confidentiality requirements:

Summary of Statutes Pertaining to Confidential Public Health Records

All HIV/AIDS case reports and any information collected or maintained in the course of surveillance-related activities that may directly or indirectly indemnify an individual are considered confidential public health record(s) under New York State Health Law, Article 27-F and must be handled with the utmost confidentiality. Furthermore, Public health Law, Article 27-F prohibits the disclosure of HIV/AIDS related public health records that contain personally identifying information to any third party, unless authorized by law for public health purposes, or by the written consent of the individual identified in the record or his/her guardian/conservator. Except as permitted by law, any person who negligently discloses information contained in a confidential public health record to a third-party subject to civil and criminal penalties. Any person who willfully or maliciously discloses the content of a public health record, except as authorized by law, is subject to civil and criminal penalties. Any willful, malicious, negligent disclosure of information contained in a public health record in violation of state law that results in economic, bodily or psychological harm to the person named in the record is punishable as provided in Public health Law, Article 27-F. Any person who is guilty of confidentiality infringement of the foregoing type may be sued by the injured party and shall be personally liable for all actual damages incurred for economic, bodily, or psychological harm as a result of the breach. Each disclosure in violation of New York State Law is a separate, actionable offense.


Because an assurance of case confidentiality is the foremost concern of New York State Department of health AIDS institute, any actual or potential breach of confidentiality shall be immediately reported. The AIDS institute has a special unit that takes Article 27-F complaints, called the Special Investigation Unit (SIU). Its HIV Confidentiality Hotline is 800-9625065. In the event of any suspected breach, staff shall immediately notify SIU. Any evidence of an actual breach shall be reported to the law enforcement agency that has jurisdiction. If the Department of Health/AIDS institute finds an agency violated Article 27-F’s HIV Confidentiality or HIV testing requirements, the DOH may require the agency to take corrective action and/or may impose a fine of up to $5,000 per violation. Criminal penalties may be imposed if the violation was “willful” (§ 2783(2)).


Contractor Confidentiality Pledge


I recognize that in carrying out my assigned duties, I may obtain access to private information about persons diagnosed with HIV or AIDS that was provided under an assurance of confidentiality. I understand that I am prohibited from disclosing or otherwise releasing any personally identifying information, either directly or indirectly, about any individual named in any HIV/AIDS confidential public health record. Should I be responsible for any breach of confidentiality to ensure the privacy of protected health information contained in any electronic record, paper documents, or verbal communications to which I may gain access shall not expire, even after my contract affiliation with Loyalty Staffing Solutions has terminated.

By my signature, I acknowledge that I have read, understand and agree to comply with the terms and conditions above.

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