CONFIDENTIALITY AGREEMENT 

OVERVIEW OF PRIVACY POLICIES

Optimal Wellness Medical (OWM) policy and federal regulations protect the privacy of our patients’ health information. The Health Insurance Portability and Accountability Act (HIPAA) is a set of federal rules that defines
what information is protected, sets limits on how that information may be used or shared, and provides patients with certain rights regarding their information. OMW has its own policies that reflect these regulations as well as best ethical standards.

These rules protect information that is collected or maintained, (verbally, in paper, or electronic format) that can be linked back to an individual patient and is related to his or her health, the provision of health care services, or the payment for health care services. This includes, but is not limited to, clinical information, billing and financial information, and demographic/scheduling information.

OWM policy and HIPAA regulations limit the use or sharing of protected patient information to the following purposes:
providing treatment, obtaining payment for services, certain health care administrative functions and when required or permitted by law.

Any other use or disclosure of protected information requires written authorization from the patient. For all uses or disclosures other than treatment, only the minimum amount of
information necessary will be shared on a need to basis. The Notice of Privacy Practices describes to patients how we may use or disclose their health information and patient rights regarding their protected health
information.

CONFIDENTIALITY AGREEMENT FOR VISITORS IN CLINICAL AREAS

As a visitor at Optimal Wellness Medical you are required to conduct yourself in strict conformance to all applicable laws and OWM policies governing confidential information. Simply by being in the Medical Office, you may encounter confidential patient information. Care is often coordinated in semi-public environments
where there is the risk that patient information may be heard or viewed by individuals not directly involved in the patient’s care. OWM has polices intended to limit the risks of such incidental disclosures of patient information.
You may see or hear information related to OWM patients (such as charts and other paper and electronic records, demographic information, conversations, service dates, patient financial information, etc.). Any patient information you see or hear, either incidentally or by shadowing must be kept confidential. By signing below, you are agreeing to abide by OWM policies regarding confidentiality of patient health information.
As a condition of and in consideration of, my use, access, and/or disclosure of confidential information, I understand and agree to the following:

I will access, use, and disclose confidential information only as permitted by OWM hosts. This means that I will only access, use, and disclose confidential information that I have been given authorization to access, use, and disclose.

I understand that any fraudulent application, violation of confidentiality or any violation of the above provisions will result in thE termination of my privilege to observe and I may be subject to legal liability as well.

My signature below indicates that I have read, accept, and agree to abide by all of the terms and conditions of this Agreement and agree to be bound by it.

Thanks for submitting!