SAMPLE POLICY

Confidentiality of Health Information

ORIGINATED BY: Policy Standardization Committee

NUMBER:
REVIEWED BY: Executive Committee
PAGE: 1 of 2
SUBJECT: Confidentiality of Health Information
ORIGINATED: 03/97
REVISED:

POLICY: Confidentiality of health records prepared in hospitals is legislated by the provincial

government in the statute known as Hospitals' Act. All health information related to an identified
individual must be treated as confidential. This information may be in written, verbal or other form.

PROCEDURE:
1. All individuals, institutions and organizations maintaining, handling or processing health
information shall:
o have written policies regulating access to, release of, transmittal and destruction
of health information.
o educate all their employees with regard to maintaining confidentiality of
information and have them sign a pledge of confidentiality. This procedure shall
apply also to researchers, volunteers, contracted individuals and employee of
firms and corporations performing contracted work.
2. Health information shall be accessed or released only for:
o direct care use - when requested by a physician or health care facility responsible
for the direct care of the individual;
o individual use - when authorized by the individual or his legally authorized
representative;
o secondary use - when requested by properly authorized persons or agencies;

o legal use - when required by law.

3. When health information is sent to any service organization for processing, the contract
shall include an undertaking by the recipient and confidentiality will be maintained.
PLEDGE OF CONFIDENTIALITY
I have read and reviewed the policy on Confidentiality of Health Information. I understand that all
patient/hospital information to which I have access is confidential and is not to be communicated to
anyone, in any manner, except as specified in the policy.

Name: __________________________________________________
(Print Full Name)
Signature: __________________________________________________

Witnessed: __________________________________________________

Dated: __________________________________________________

Copyright 2001 NLHRA All Rights Reserved.