Visitor Confidentiality Acknowledgement


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Visitor Confidentiality Acknowledgement

As a visitor to Minnesota CarePartner, LLC it is important that you understand your responsibility to maintain the confidentiality of any protected health information you may encounter during your visit.

The laws governing the confidentiality of such information:

  1. Health Insurance Portability and Accountability Act, [HIPAA])

These laws prohibit disclosure of any information regarding a person’s presence and/or status without the consumer's explicit written consent.

As a visitor, this means that you may not disclose any written or oral information regarding any consumer, past or current. This includes any reference to identity, physical whereabouts, diagnosis, treatment, and prognosis.

Any person who violates these regulations is subject to a fine of $500 for the first offense and not more than $5000 in the case of each subsequent offense.

By entering your name below and signing this form, you are attesting:

  1. You have read and understood the information above;
  2. You are aware that any information you may learn as a result of your visit must be kept confidential; and
  3. You may be subject to legal ramifications if you violate federal confidentiality laws.

 

Client First Name:   Client Last Name:

Visitor Legal Name: 

Visitor Email Address: 

 

Leave this empty:

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Signature Certificate
Document name: Visitor Confidentiality Acknowledgement
lock iconUnique Document ID: 458e581eeb2661557a077cca24877461229bb4a6
Timestamp Audit
August 21, 2021 5:27 am CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 101.50.105.75, 127.0.0.1, 198.71.243.23, 0.0.0.0
August 21, 2021 9:34 am CSTVisitor Confidentiality Acknowledgement Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.184.37
August 24, 2021 11:46 am CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153, 127.0.0.1, 198.71.243.23, 0.0.0.0
August 24, 2021 1:05 pm CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153, 127.0.0.1, 198.71.237.56, 0.0.0.0
August 24, 2021 1:58 pm CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 101.50.105.41, 127.0.0.1, 198.71.237.56, 0.0.0.0
August 24, 2021 2:04 pm CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 101.50.105.41, 127.0.0.1, 198.71.237.56, 0.0.0.0
August 24, 2021 2:06 pm CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 101.50.105.41, 127.0.0.1, 198.71.237.56, 0.0.0.0
August 25, 2021 11:57 am CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153, 127.0.0.1, 198.71.237.57, 0.0.0.0
March 9, 2022 11:20 am CSTRoot Recovery - roots@mncarepartner.com added by Roots Recovery - rootsforms@mncarepartner.com as a CC'd Recipient Ip: 206.84.184.37