SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE

STATEMENT OF PATIENT CONFIDENTIALITY

It is to be clearly understood that privacy is a basic right of every patient treated in programs or facilities of the School of Medicine. This statement is to certify my agreement and understanding of the patient confidentiality I am expected to observe as member of the faculty, staff, or student body of Southern Illinois University School of Medicine.

Section 3 of the Medical Patient Rights Act (410 ILCS 50/1 et seq.) prohibits disclosure of the nature or details of services provided to patients, except to (1) the patient, (2) the party making treatment decisions if the patient is incapable of making such decisions, (3) those parties directly involved with providing treatment to the patient or processing payment for that treatment, (4) those parties responsible for peer review, utilization review and quality assurance, or (5) as otherwise authorized or required by law. Consistent with this statute, I agree as follows:

Handling of Patient Records

Except as permitted by Illinois law, I will not release information pertaining to a patient unless specifically authorized to do so by the patient or the patient's legal representative. I understand that patient files, medical records, medical transcription, and patient accounts (in paper or electronic form) are not to be carried, transferred, or disseminated outside the School of Medicine without specific authorization. This includes individually-identifiable information gathered for research or other scholarly purposes. Furthermore, I recognize that failure to control access to confidential patient information (in paper, electronic, or other form) for which I am responsible is equivalent to unauthorized transfer.

Disclosure of Patient Information

Discussion or other disclosure of any information regarding a patient's medical, financial, or personal data for reasons other than the discharge of my assigned duties is inappropriate. Therefore, I will limit my discussion of any particular case to those parties with whom I must interact to assure the successful fulfillment of my duty to the patient.

Other Professional Conduct

Unless authorized or required to do so, I will not provide a diagnosis, discuss the mode of care, draw any conclusions concerning a patient's health and welfare, or provide an impression or interpretation of any medical data to the patient or to any other party.

I have read and understood the above statement. I further understand that violation of this statement constitutes a serious breach of professional ethics and may result in disciplinary action, including termination of employment or dismissal of students from the School of Medicine.

Approved by the Executive Committee, 3/16/98