HIPPA Privacy Form

, an employee of Revival Research Institute, LLC, acknowledge the confidentiality of patient health care information (“Confidential Patient Information”) that I may receive or have access to in the course of providing patient care services at participating Healthcare Facilities at which I am assigned. Patient and personnel information from any source and in any form, including oral communication, audio recording, and electronic display, is strictly confidential. Access to confidential patient and personnel information is permitted only on a need-to-know basis. It is the policy of Revival Research Institute, LLC and healthcare facilities that all users respect and preserve this right to privacy and confidentiality. Violations of this policy include, but are not limited to:

•Accessing information that is not within the scope of your job;

•Disclosing, misusing without proper authorization, or altering patient or personnel information;

•Disclosing your sign-on code and password or using another person’s sign-on code and password for accessing electronic or computerized records;

•Leaving a secured application unattended while logged on; and

•Attempting to access a secured application without proper authorization.

Violations of this policy may constitute grounds for disciplinary action up to and including termination of employment or loss of hospital privileges in accordance with Hospital procedures and/or federal or state law. I shall maintain the confidentiality of Confidential Patient Information, and in doing so shall comply with all applicable state and federal laws and regulations, including without limitation, the privacy provisions under Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the policies and procedures of each participating Healthcare Facility where I am assigned. My agreement to maintain the confidentiality of Confidential Patient Information shall survive the termination of my employment with Revival Research Institute, LLC and the conclusion of any assignment at the participating Healthcare Facility.