3 2. I will not have access to any information unless it is necessary for my AHS responsibilities. I will not have access to any other information, including my own health information or information about a family member, friend, colleague or person outside of my jurisdiction. There are other procedures (including in the management of health information) that would allow me or others to adequately request access to health Name First NameJoi of the position (doctor, analyst, nurse, etc.) Identification number (For CPSA doctor #)PhoneEmailRoll (send your form to the office indicated in parentheses) AHS staff / Branch (manager / supervisor) Medical staff, medical students, residents / trainees (zone medical office) Provide the volunteer from the main area (volunteer resources) Coordinator) Researcher (depot owner) Student or educator (liaison with the educational institution) Board member (office Of the Board) Midwives (Chief Nursing) Agent)Page 1 of 2 Confidentiality and User Agreement07922(Rev2015-11) Agreement (continued)Appropriate Collection, Use and Disclosure of Information (continued d)3. 5 I will take reasonable steps to keep all AHS information private and confidential and to prevent the unauthorized collection, use and/or disclosure of any AHS information with which I come into contact I agree that the obligation to maintain the confidentiality of AHS information will continue even after my AHS liabilities If I am informed of a violation of any of the above policies or a potential or actual violation of I am Aware of confidentiality, I will inform my supervisor immediately. I will also inform the AHS Information and Privacy Office or Information Risk Management as soon as the sanction is granted.17 I understand and acknowledge that AHS may, in its sole discretion, conduct random audits of AHS systems and review my use of an AHS system without understanding that AHS may, in its sole discretion, revoke or restrict my access to AHS information or AHS systems for any reason with reference to policies, laws, laws, or I acknowledge that I have read the above guidelines and the implications for the implementation of these policies and/or this (Rev2015-11) understand. Page 2 of 2I accept the rules and expectations described in this Agreement: Name (print) SignatureDate (y- mon-dd) Privacy and User Agreement 16. If I become aware of a breach of any of the above policies or a potential or actual breach of confidentiality, I will notify my supervisor immediately. I will also inform the AHS Information and Privacy Office or Information Risk Management as soon as possible. Alberta Health Services (SSA) is responsible for protecting the privacy of the information it collects, uses, stores and discloses in the course of its business.

You will have access to AHS information as part of your duties and responsibilities related to your role at AHS. This document describes how, when acting as an ahs partner (defined in the Health Information Act), you must process AHS information, including AHS information systems, and helps you comply with relevant AHS guidelines. (See Information Management and Technology Guidelines onwww.albertahealthservices.ca/210.asp.) System Security8. I will keep all AHS login information, such as my user password, confidential and will not disclose it 4 I will ensure that the information I enter into an AHS system is complete and accurate. I will dispose of any information that I access from an AHS system (whether electronic or paper) in an insecure manner, as explained in the AHS Guidelines, and I will use reasonable means to ensure that, while accessing information on an AHS system that is not seen or obtained by unauthorized persons (secure my computer, be discreet when displaying data).6. I understand that AHS retains and controls all information contained in an AHS system, as well as information in paper form. I will not collect, use, transmit or disclose AHS information except as permitted by Security`s AHS policies8. I will keep all AHS system credentials, such as my user password, confidential and will not disclose these credentials to third parties I am responsible for using an AHS system under my login I will not leave my workstation unattended without disconnecting or securing my workstation, If I believe that my login information is known to another person, I will immediately change my password and inform AHS Information Risk Management that I cannot download or install applications or programs on an AHS system without the administrator`s consent for those specific AHS terms14. 15. I agree that the obligation to maintain the confidentiality of AHS information will remain even after the end of my AHS responsibilities.

This form must be completed by all staff, medical staff, young doctors/interns, volunteers, researchers, students, educators, board members and midwives. Completion by all medical staff is a prerequisite for the appointment of staff. Alberta Health Services (SSA) is responsible for protecting the privacy of the information it collects, uses, stores and discloses in the course of its business. You will have access to AHS information as part of your duties and responsibilities related to your role at AHS. This document describes how, when acting as an ahs partner (defined in the Health Information Act), you must process AHS information, including AHS information systems, and helps you comply with relevant AHS guidelines. (See Information Management and Technology Guidelines) This form must be completed by all staff, medical staff, young doctors/interns, volunteers, researchers, students, educators, board members and midwives. Completion by all medical staff is a prerequisite for the trained staff forms to be stored in the corresponding program files. Managers/supervisors should fax forms for AHS employees to Human Resources by fax to 1-888-908-4408 or by email For AHS medical staff, please forward this signed form to the Office of Medical Affairs in their primary area after completing the required AHS privacy and security training. 2 It will be kept in accordance with the MedicalStaff forms received by AHS and considered as a legal file; All other copies may be insured, provided that you read and understand the above guidelines, and that you keep patient information, personal or other AHS confidential.

The confidentiality of information is subject to both the abthetic policy and federal and state law. You must sign this Agreement before AHS grants access to AHS information or to an electronic system owned or operated by AHS (AHS system). This agreement explains the rules and expectations associated with securing and protecting information and AHS systems. You may be required to comply with additional terms before accessing certain AHS information about the collection, use, and disclosure of information1. I will only collect, retrieve, use and disclose the minimum information necessary to carry out my duties and responsibilities related to my role at AHS (AHS Responsibilities). 4. I have all the information I access from an AHS system (electronic or paper) in an insecure manner, as explained in the AHS policies and procedures. Confidentiality Provisions14. I will take reasonable steps to keep all AHS information private and confidential and to prevent agreement (ongoing)Appropriate collection, use and disclosure of information (continued)3. I will ensure that the information I enter into an AHS system is complete and accurate, to the best of my ability It is necessary that you read and understand the above guidelines and keep confidential patient information, personal or other AHS. The confidentiality of information is subject to both the abthetic policy and federal and state law.

9. I am responsible for any use of an AHS system that is carried out under my login data. Volunteer Resources Coordinator Member of the Student Liaison Council or Educational Institutions Member of the Chief Nursing Board of Directors For AHS medical staff members, please forward this signed form to the Office of Medical Affairs in their primary area after completing the required AHS Privacy and Security training. It is kept on file in accordance with MedicalStaff`s statutes. 13. I cannot download or install an application or program on an AHS system without the administrator`s permission for that particular AHS system. Role (send your form to the office indicated in parentheses) AHS employees / subsidiary (manager / supervisor) Medical staff, medical students, junior doctors / trainees Forms completed by AHS are considered a legal file; all other copies can be safely destroyed. 19. I confirm that I have read the above guidelines and understand the implications for compliance with these guidelines and/or this Agreement. 7. I will not collect, use, transmit or disclose any information from AHS except as permitted by AHS policies and procedures.

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