Confidentiality agreement for medical staff members
As a member of the medical staff who is involved in the evaluation and improvement of the quality of patient care rendered at __________ Medical Center (i.e., medical staff officer, department chair, section chief, committee chair or member, or an individual physician working under the auspices of a peer review committee), I recognize that I will be provided with, and have access to, very sensitive and confidential information regarding practitioner credentialing, performance improvement and peer review activities.
I understand that it is critical to maintain all such information, and any and all discussions and deliberations regarding the same, in strict confidence.
I agree to make no disclosures of such confidential information outside of appropriate meetings, except in the following very limited circumstances:
- when the disclosures are to another practitioner on the medical staff acting in an "official" medical staff organization capacity (i.e., a medical staff officer, department chair, etc.)
- when the disclosures are to an authorized employee of the hospital and are for the purpose of conducting legitimate medical staff affairs
- when the disclosures have been authorized, in writing, by the
Medical Center
Any such disclosures shall always be made in a confidential, private setting.
I understand that my breach of this Agreement may compromise the interests of __________
(1) dismissal from my committee assignment and/or elected or appointed position with the medical staff organization
(2) loss of available legal protections (including loss of indemnification for any litigation costs and expenses)
(3) disciplinary action as deemed appropriate by the Medical Executive Committee (see medical staff bylaws, correction active); and/or
(4) other appropriate legal action
_____________________________________
Date Signature