Non-disclosure | West Orlando Internal Medicine

Non-Disclosure Agreement

Required Optional Completed

Covered Entity information systems contain confidential records pertaining to business operations, patients, business associate vendors or subcontractors, and COVERED ENTITY employees. Because this information is vital to the operation of COVERED ENTITY in providing quality service, it must be protected (“protected information”). As such, in accordance with current HIPAA and Omnibus regulations, state law and COVERED ENTITY policies governing the access, use, and disclosure of protected health information, you have the responsibility to protect such data.  This agreement is not intended, and should not be construed, to limit or prevent an employee from exercising rights under the National Labor Relations Act.

 The purpose of this agreement is to provide you with information to assist you in understanding your duty and obligations relative to confidential information. Your signature on this document indicates that the information contained herein has been explained to you, you received a copy of this document, and that you understand the rules set forth. In exchange for employment, continued employment, or contract, the receipt and sufficiency of which is hereby acknowledged. 


 1. To respect the privacy and confidentiality of any information you may have access to through COVERED ENTITY computer network and that you will access or use only that information necessary to perform your job.

 2. To refrain (whenever possible) from communicating information about a patient or an employee in a manner that would allow others to overhear such information and further to refrain from discussing a patient’s information with anyone not permitted access to such information in accordance with COVERED ENTITY established policies or that particular patient’s wishes (e.g., friends, relatives, visitors, family members or patients, etc.).

 3. To disclose confidential patient or staff information ONLY to those authorized to receive it.

 4. To safeguard and not disclose your password or user ID code or any other authorization you may have that allows your access to protected information. You accept responsibility for all entries and actions recorded using your password and user ID code.

 5. Not to attempt to learn or use another user password and user ID code to log-on to COVERED ENTITY computer network.

 6. To immediately report to the HIPAA Privacy Officer any suspicions that your password and user ID code have been compromised.

 7. Not to release or disclose the contents of any patient or staff records or reports except to fulfill your work assignment.

 8. To obtain the approval for use of portable media devices from the Privacy Officer, to obtain approval to copy any of COVERED ENTITY data, exclusive of patient and employee personal information and protected health information to a portable media device from the HIPAA Privacy Officer, to maintain the security of data on portable media devices, and to connect portable media devices to a computer secured by the most up to date antivirus software and operating patches as recommended by the HIPAA Privacy Officer.

 9. Not to remove or copy any protected information or reports from their storage location except to fulfill your work assignment.

 10. Not to sell, loan, alter or destroy any protected information or reports except as properly authorized within the scope of your job assignment.

 11. Not to leave your computer terminal or workstation unattended without locking or turning off your terminal before leaving your work area or securing hardcopy information so that it may not be disclosed to unauthorized persons.

 12. Not to access or request any protected information that is not necessary to perform your assigned job function.

 13. Not to permit others to access COVERED ENTITY computer network using your password or ID code.

 14. To permit your access to COVERED ENTITY computer network to be monitored;

 15. Not to download or make copies of any software or applications without proper authorization or license.

 16. Not to access or download any pornography or other illegal materials or perform any illegal activity such as gambling while on COVERED ENTITY computer network.

 17. Not to use our corporation’s computer network to send/forward harassing, insulting, defamatory, obscene, offending or threatening messages.

 18. To promptly report any suspected or known unauthorized access, use, or disclosure of protected information.

 19. To abide by COVERED ENTITY “Notice of Privacy Practices,” the policies and procedures set forth by COVERED ENTITY, and current federal and state regulations governing privacy issues.

 20. To restrict personal use of the corporation’s computer network to meal and break periods and to follow COVERED ENTITY established policies governing such personal use.

 21. Not to store personal files or electronic information on COVERED ENTITY computer network.

Upon termination of my employment or services with COVERED ENTITY, I shall promptly deliver to COVERED ENTITY all protected information and documents, including, but not limited to, such things as medical information, manuals, notebooks, reports, patient, employee and vendor lists and information, and anything else owned by COVERED ENTITY or to which COVERED ENTITY is entitled and which is in my possession or under my control.

In the event of a breach or a threatened breach of any of the preceding provisions, COVERED ENTITY shall, in addition to the remedies provided by law, have the right and remedy to have such provisions specifically enforced by any court having jurisdiction, it being acknowledged and agreed that any breach of any of these provisions will cause irreparable injury to COVERED ENTITY.

This agreement supersedes and replaces any prior or existing understanding between COVERED ENTITY and me relating generally to the same subject matter.

If any of the above numbered provisions, in whole or in part, of this agreement is declared void or unenforceable by a court of competent jurisdiction, the remainder this agreement or the remainder of such provisions shall remain in full force and effect. 

This agreement shall be governed by and construed in accordance with the laws of the State of Florida.

I further understand that the duties and obligations set forth in this document will continue after the termination, expiration, and cancellation of this agreement to include my termination of employment. I also understand my password and user ID code can be temporarily or permanently revoked or I can be terminated if I fail to abide by the rules set forth. 

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