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Facility Information

Confidentiality Agreement

By submitting this form, I agree to the following. Facility employees/contractors and partners of All-Stat Portable Xray will have access to confidential information, both written and oral, in the course of using this software. It is imperative that this information is not disclosed to any unauthorized individuals to maintain the integrity of the patient information. An unauthorized individual would be any person that is not currently a facility employee/contractor or employee of All-Stat Portable Xray. Any disclosures may only occur at the direction of the patient and/or patient representative. I have read and understand the practice’s policies with regards to privacy and Security of personal health information. I agree to maintain confidentiality of all information obtained by this software including, but not limited to, financial, technical, or propriety information of the organization and personal and sensitive information regarding patients, employees, and vendors. I understand that inappropriate disclosure or release of patient information is against the law.