/f

77
J_ontCommissionJointCommissionlnffiimdSurveyObesnation
International
l, the undersigned, have been granted permission by Director RSUP H. Adam Malik Medan
(the "hospital") and Joint Commission lntemational ("JCl") to observe an accreditation survey of
the hospitalto be conducted by Joint Commission lnternational on
RSUPN. Dr. Cioto Manqunkusumo Jakarta (the survet'').

! am informed that the hospital considers all information observed

during the survey as

confidential information and subiect to applicable local or international privacy laws. I agree
to be bound by the hospital's confidentiali$ and privacy policies and applicable laws
regarding privacy and security.
I am informed that JCI treats accreditation survey information as strictly confidential and that
such confidential accreditation infonnation may be further privileged and protected by law from
unauthorized disclosure.
I understand and agree to be bound by JCI's policy of confidentiality and applicable law regarding
accreditation information. Sp*ifically, I agree to hold in stric't mnfidence all information relating to

the hospital's accreditation survey, including but not limited to, review of records interviews,
observations and discussions in or to which I am a participant or observer.

I underctand and agree that I am thereby prohibited from disclosing any such information to any

third parg in any manner that could identi! or connect the hospital with the information
disclosed,

I am informed, in addition, that JCI and the hospital treats patient information as strictly
confidential, that patient information is further protected by law, that JCI's authorization to
access confidential patient information does not extend or apply to me as an observer of the
survey and that I am thereby prohibited from accessing confidential patient information in any
form, including written, verbal, electronic or other form at any time during the survey,
including, but not limited to, during the surveyors' review of records, interviews, observations
and discussions in or to which I am a participant or observer, unless such access is expressly
authorized by the patient involved"
I understand and agree to be bound by JCI's policy of confidentialifi and applicable law
regarding patient information.

Agreed by:
GBSERVER:

Dr. Ctlerry Siregar, M.Kes

122AA2

24Mav 2016
Date

M.Kes
121989011001

24 Mav 2016
Date

77

WlontCommission
lnternational

CS{FIDENtrALTTT AGREETENT
for J oint Commission lntemational Su rvey Observation
l, the undersigned, have been granted permission by Director RSUP H. Adam Malik Medan
(the "hospital") and Joint Commission lntemational fJCl') to observe an accreditation survey of
the hospital to be conducted by Joint Commission lnternational on
RSUPN. Dr. Cioto Manqunkusumo JakFrta ("the survef).

I am informed that the hospital considers all information observed during the survey as
confidential information and subject to applicable local or international privacy laws. I agree
to be bound by the hospital's confidentiality and pnvacy policies and applicable laws
regarding privacy and securiS.
I am informed that JCI treats accreditation survey information as strictly confidential and that
such confidential accreditation information may be further privileged and protected by law from
unauthorized disclosure.
I understand and agree to be bound by JCI's policy of confidentiality and applicable law regarding
accreditation inbrmation. Specifically, I agree to hold in strict confidence all information rclating b

the hospital's accreditation survey, including but not limited to, review of records interviews,
observations and discussions in or to whicfr I am a participant or observer.

I understand and agree that I am thereby prohibited from disclosing any such information to any
third party in any manner that could identiff or connect the hospital with the information

disclosed.

I am informed, in addition, that JCI and the hospital treats patient

information as strictly
protected
patient
by law, that JCI's authorization to
information is further
confidential, that
patient
information does not extend or apply to me as an observer of the
access confidential
survey and that I am thereby prohibited from accessing confidential patient information in any
form, including written, verbal, electronic or other form at any time during the survey,
including, but not limited to, during the surveyors' review of records, interviews, observations
and discussions in or to which I am a participant or observer, unless such access is expressly
authorized by the patient involved.
I understand and agree to be bound by JCI's policy of confidentialihT and applicable law
regarding patient information.

Agreed by:
Marince Faniaitan, S.Kep, Ners, M.Kes
997032001

24Mav 2016
Date

Hospital

Malik

Refnealdi, M.Kes
21989011001

24Mav 2O16
Date