AFFIDAVIT OF CONFIDENTIALITY & COMPLIANCE

  • AFFIDAVIT OF CONFIDENTIALITY & COMPLIANCE

  • Cascadia Clubhouse, Skagit County

    AFFIDAVIT OF CONFIDENTIALITY & COMPLIANCE

     

    This document combines federal HIPAA requirements with the specific mandates of Washington State law. It is designed to be signed by anyone with access to member data at Cascadia Clubhouse.

    Name:
     
     
    Circle position that pertains to you:
    Staff           Volunteer          Board Member          Contractor
     

    I, the undersigned, understand that in the course of my duties at Cascadia Clubhouse, I may have access to "Confidential Information" and "Protected Health Information" (PHI) regarding adults with developmental disabilities. I hereby declare and agree to the following:

     

    1. Federal HIPAA & State Health Privacy

    I agree to comply with the Health Insurance Portability and Accountability Act (HIPAA) and the Washington My Health My Data Act (MHMDA). I will:

    • Access, use, and disclose only the "minimum necessary" information required to perform my duties.
    • Protect all electronic and physical records from unauthorized access, loss, or theft.
    • Respect the rights of members to access or request the deletion of their health-related data.

    2. Oath of Confidentiality (RCW 71A.14.070)

    In accordance with RCW 71A.14.070, as a condition of my involvement with Cascadia Clubhouse, I agree not to divulge, publish, or otherwise make known to unauthorized persons or the public any information obtained in the course of my duties where the release of such information may identify a member. I recognize that unauthorized release of confidential information may subject me to civil liability under state law.

     

    3. Mental Health & Disability Records (RCW 70.02.230)

    I acknowledge that records regarding disability or mental health services are strictly protected under RCW 70.02.230. I will not disclose these records except for authorized service coordination (e.g., with DSHS) or in a life-threatening medical emergency.

     

    4. Mandatory Reporting Requirement (RCW 74.34.035)

    I understand that I am a Mandated Reporter under Washington law. If I have reasonable cause to believe that a vulnerable adult has suffered abuse, neglect, abandonment, or financial exploitation, I must immediately report the incident to the Department of Social and Health Services (DSHS) and/or law enforcement as required by RCW 74.34.035. I understand that my identity as a reporter remains confidential unless required by law or judicial proceeding.

     

    5. Continuing Obligation

    I understand that my duty to maintain the confidentiality of Cascadia Clubhouse members continues even after my employment or volunteer service with the organization has ended.

     

    Affirmation: I certify that I have read and understand the privacy policies of Cascadia Clubhouse and the Washington State statutes cited above. I agree to abide by these terms to ensure the safety and dignity of our members.

     

    Signature:
     
     
    Date:
     
    Printed Name:
     
     
     
     

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