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:
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:
Client First Name: Client Last Name:
Visitor Legal Name:
Visitor Email Address:
Leave this empty:
Your legal name
Your email address
Click on "Agree & Sign" to legally sign this document and agree to the WP E-Signature Terms of Use. If you have questions about the contents of this document, you can email the document owner.
Document Name: Visitor Confidentiality Acknowledgement
Click on "Agree & Sign" to legally sign this document and agree to the WP E-Signature Terms of Use.
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