HomeMy WebLinkAboutHIPAA Confidentiality Agreement Updated 25.11.17 CITY OF MONROE, MICHIGAN
GROUP HEALTH PLANS
HIPAA CONFIDENTIALITY AGREEMENT
Name of Authorized Employee
Date:
Recitals:
A. City of Monroe, Michigan (the “Employer”) sponsors and maintains the following
group health benefits to eligible employees and retirees (collectively referred to as the “Plan”):
● Medical, Dental, and Vision Plans for Active and Retired Eligible Employees
● Group & Voluntary Life
● Long-Term Disability
● Hospital Indemnity, Critical Illness, & Accident
● Employee Assistance Program
● Healthcare & Dependent Care Flexible Spending Account
● Retiree Healthcare Savings Program
B. The Health Insurance Portability and Accountability Act of 1996, as amended, and its
implementing privacy and security regulations (collectively referred to as “HIPAA”) restrict the
Employer ’s and Plan’s ability to use and disclose certain health information known as “protected
health information” (“PHI”) and may require the Plan and the Employer to implement security
measures with respect to electronic protected health information (“ePHI”).
C. It is the Employer ’s policy to ensure that the Plan and the Employer fully comply with
HIPAA requirements. To that end, the Employer has established written HIPAA Privacy and
Security Policies and Procedures (“HIPAA Policies”) (a copy of which are attached to and made
part of this Agreement) and has designated a limited group of workforce members referred to as
“Authorized Employees” who may have access to PHI for purposes of administering the Plan.
D. The Employer has appointed the Human Resources Director and City’s Finance
Director of the Employer as the HIPAA Privacy Officer and the HIPAA Security Officer,
respectively.
E. The above-named Employee has been designated as an Authorized Employee under the
Employer ’s HIPAA Policies. For a full list of Authorized Employees, see HIPAA Privacy and
Security Policies and Procedures Section 2.3.
Agreement:
As an Authorized Employee, I agree and acknowledge, during and after my employment with the
Employer, that:
1. I have received a copy of and have read the HIPAA Policies and I have attended a HIPAA
training session.
2. I will comply with the Employer ’s HIPAA Policies that are in effect as of the signing of
this agreement. Amendments to the Employer ’s HIPAA Policies will require a new
confidentiality agreement.
3. I will not disclose any PHI to any person or entity for any reason or purpose whatsoever
except in accordance with the Employer ’s HIPAA Policies.
4. If I discover, become aware of or otherwise attain knowledge of a violation of HIPAA
requirements, as set forth under our HIPAA Policies, or a Breach of Unsecured PHI, I will
immediately report such violation or breach to the HIPAA Privacy Officer or Security Officer.
5. Upon my termination of employment with the Employer, I will deliver to the Employer
all PHI or ePHI that is in my control without retaining copies or summaries of any such material.
6. The restrictions set forth above are reasonable in scope and duration and are necessary for
the purpose of complying with HIPAA.
7. I agree that the breach or threatened breach of the restrictions set forth above may cause
irreparable injury or damage to the Employer for which the Employer would have no adequate
remedy under HIPAA or other laws. I therefore agree that, in addition to all sanctions and
remedies provided under the HIPAA Policies and law, the Employer may seek equitable relief in
the form of specific performance, temporary restraining order, temporary or permanent
injunction or any other equitable relief that may then be available to prevent such breach and/or
threatened breach and/or continued breach of the restrictions set forth above.
8. The failure of the Employer to enforce any provision or obligation under this Agreement
shall not constitute a waiver thereof or serve as a bar to the subsequent enforcement of such
provision or obligation or of any other provisions or obligations under this Agreement.
9. This Agreement shall be binding upon and the benefits thereof shall inure to the benefit
of the successors and assigns of the Employer.
10. If any provision of this Agreement is ruled to be invalid, unenforceable, or illegal, and
cannot be cured as described above, the rest of this Agreement shall remain enforceable and the
Agreement will be construed as if it never contained the invalid, unenforceable, or illegal
provision.
11. This Agreement constitutes the entire agreement between me and the Employer regarding
this subject matter. There is no statement, promise, agreement, or obligation in existence which
conflicts with the terms of this Agreement and this Agreement supersedes all previous proposals,
communications, and offers between the parties regarding the subject matter of this Agreement.
Any change or modification of this Agreement must be in writing and must be signed by both me
and the Employer.
12. This Agreement shall be construed in accordance with the laws of the State of Michigan.
I hereby certify that I have read this HIPAA Confidentiality Agreement and accept and
agree to its terms:
Print Name: , Authorized Employee
Date