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2. Acknowledgement of Receipt of HIPAA Manual*

   I understand that while performing my official duties I may have access to protected health information. I understand that:

   ・Protected health information is individually identifiable health information that is created, maintained, or used by Madison County.

   ・Special precautions are necessary to protect this type of information from unlawful or unauthorized access, use, modification, disclosures, or destruction.

   Furthermore, I acknowledge and understand that, as an employee, volunteer, trainee or other person who conducts work under the direct control of Madison County, I am prohibited from releasing any protected health information (PHI) which may come to my attention in the course of my duties to any unauthorized person. Moreover, I acknowledge and understand that any breach of confidentiality, client or otherwise, resulting from my written or verbal release of health information or records provides grounds for disciplinary action or other appropriate corrective measures, which may include my immediate termination as an employee or immediate termination of my contractual or volunteer relationship with Madison County.

   By checking the "I agree" box below, I, the undersigned, acknowledges receiving a copy of the Madison County HIPAA Privacy Policies and Procedures Manual.

   1. I agree.
4. Electronic Signature*
5. Date*
   Date
7. Print Name*
8. Department*
10. Upon submitting your Electronic Acknowledgment of Receipt Form, you will be automatically redirected to the HIPAA Privacy Policies and Procedures for download
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12. 1. Receive an email copy of this form.
13. Email address

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