Confidentiality & HIPAA Privacy Agreement form Volunteers, Interns or individuals participating in a shadowing experience, have the obligation to treat all information about Prime employees in a strictly confidential manner. Discussing or electronically sharing confidential information with neighbors, friends, or relatives is prohibited. When discussing positive aspects of your volunteer, internship or shadowing experience, please keep confidentiality in mind at all times and do not share names or other confidential information. You may be made aware of PHI (Protected Health Information). Understand that federal and state law, including the Health Insurance Portability and Accountability Act (“HIPAA”), protects the privacy and confidentiality of “protected health information” (“PHI”). PHI is defined as any information that identifies an individual and that relates to the past, present or future physical or mental health or condition of an individual or the provision of health care to an individual.I agree to keep all confidential information, including PHI specific to Prime employees in strict confidence. I understand that failure to do so will result in termination of my participation in the volunteer, internship or job shadowing experience and may expose me to potential legal liability.Name(Required) First Last Signature(Required)Date(Required) Month Day Year Email(Required) Prime Inc.P.O. Box 4208 Springfield, MO 65808 Nationwide/ 800-321-4552 Fax/ 417-521-3994
