CITY OF CHICAGO
DEPARTMENT OF PUBLIC HEALTH
HIPAA Compliance Acknowledgment Statement for Non-Employee
At CDPH, we are committed to respecting our patients’ and clients’ rights to privacy so the
confidentiality of their records is a primary concern. You may have access to information about
our patients / clients that cannot be shared with anyone other than staff immediately involved in
providing care or service to them. We therefore, require that you sign the following confidentiality
statement.
I understand and agree that in performance of my duties with the Chicago Department of
Public Health, I must hold all patient / client information in confidence.
I acknowledge that I have received and read the Chicago Department of Public Health’s
HIPAA 100 Training Manual. I understand that I must adhere to the standards, policies and
procedures detailed in the document. I understand that if I violate a provision of HIPAA regarding
the privacy and confidentiality or protected health information I may be fined and / or imprisoned
through sanctions imposed by the Department of Health and Human Services, Office of Civil
Rights. In addition, my role and / or program at CDPH may be terminated.
I understand that if I have any questions about my duties and responsibilities, while
assigned to CDPH, regarding privacy and confidentiality of protected health information that I
may contact my CDPH supervisor or the City of Chicago Privacy Officer at (312) 747-2237 for
further information.
Signature required:
Check one that applies:
Contract Internship
Student Volunteer
___________________________________________ _____________________
(Print Name) (Date)
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(Signature)
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(Affiliation)
Revised: March, 2004