I, the undersigned, have been informed of Home Companion Services of New York, Inc.'s (HCS) policy and procedure on confidentiality of personal health information as described in the Confidentiality Policy, which is in accordance with state and federal law and which is available for me to read at my request.

I also acknowledge that I am aware of and understand the corporate policies of HCS regarding the security of personal health information including the policies relating to the use, collection, disclosure, storage and destruction of personal health information.

In consideration of my employment or association with HCS and their related properties, and as an integral part of the terms and conditions of my employment or association, I hereby agree; pledge, and undertake that I will not at any time during my employment or association with HCS, Inc., or after my employment or association ends, access or use personal health information, or reveal or disclose to any persons within or outside HCS, Inc. any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable legislation, laws, regulations, and Corporate and departmental policies governing proper release of information.

I further understand that this information is privileged and confidential regardless of format: electronic, written, oral or observed.

I understand that I may view, use, disclose, or copy information only as it is related to the performance of my job duties.

I understand that my obligation outlined above will continue after my employment / contract / association with HCS, Inc. and its related business enterprises end.

I further understand that my obligations concerning the protection of the confidentiality of personal health information relate to all personal health information I acquire through my employment / contract / association with HCS, Inc.

I also understand that unauthorized use or disclosure of such information will result in a disciplinary action up to and including termination of employment / contract / association, the imposition of fines pursuant to state and federal laws, and report to my professional regulatory body.

I have been informed of the contents of HCS' Personal Health Information Confidentiality Policy and the consequences of a breach.

I acknowledge that my signature on this pledge of confidentiality signifies I have read, understand, and am committed to its principles.

I understand that this signed and dated document will become part of my permanent employment personnel record.

I have discussed the Personal Health Information Confidentiality Policy and the consequences of a breach with the above named.