I (Print full name)

Acknowledge that the Confidentiality of patient health care information I mayreceive or have access to in the course of providing care services topatient at afacility assigned by Elohim Medical Staffing Agency, Inc. I shall maintain confidentiality of patient’s confidential informationand by doing so am complyingwith all the applicable state and federallaws and regulations including the HealthInsurance Portability andAccountability Act (HIPAA) and also the policies andprocedures of each health care facility I am assigned at

My agreement is to maintain confidentiality of patient confidential information in any assignment at any facility assigned by Elohim Medical Staffing Agency, Inc.