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PROGRAM FOR HEALTH CARE TO UNDERSERVED POPULATIONS Volunteers Pledge of Confidentiality

I, _______________________________________(please print), have requested to be a volunteer with the Program for ealth Care to !nderserved Populations (P C!P)" I understand that as a volunteer I may have a##ess to #onfidential patient information or #onfidential information about the family of a patient" I also understand that #ommuni#ation of, or a##ess to su#h information, is a##eptable only in the dis#harge of my duties and responsibilities as a P C!P volunteer" $ny su#h dis#ussion shall not ta%e pla#e in publi# pla#es (elevators, lobbies, #afeterias, off premises, et#") or in the presen#e of persons not entitled to su#h information" I further understand that the law provides for possible #ivil and #riminal penalties for dis#losure of #onfidential patient information" $s su#h, I agree that I will not& 'eveal to anyone the name or identity of a patient" 'epeat to anyone any statements or #ommuni#ations made by or about the patient" 'eveal to anyone any information that I learn about the patient as a result of dis#ussions with others providing #are to the patient" I have read this statement, as e!! as the PHCUP HIPPA and P"!i#$ n"ti#e, and %nderstand m$ "&!i'ati"n t" maintain (atient #"n)identia!it$ at a!! times, &"th in and "%tside ") the #!ini#* I a'ree t" h"n"r that "&!i'ati"n and I %nderstand that an$ &rea#h ") this ("!i#$ ma$ res%!t in terminati"n )r"m v"!%nteer servi#e ith the PHCUP*

Volunteer (ignature__________________________________________________________________ Volunteer Please Print )ame___________________________________________________________ *ate_________________________________________