As a visitor, volunteer, intern, contractor, or employee (please circle one) of/at/with Daybreak Youth Services, I agree to the following: I am bound by 42 Code of Federal Regulations (CFR) Part 2, federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records; by 45 CFR Parts 160 and 164, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”); and by Revised Code of Washington (RCW) 70.96A, Treatment of Alcoholism, Intoxication, and Drug Addiction. I certify not to divulge to any unauthorized third party any information concerning a client, other than to Daybreak personnel except when: a) I have written authorized consent for the release of such information from the client. b) I am reporting child abuse or neglect per RCW 26.44. c) I am reporting information concerning a crime, which is threatened to be committed either at the program, or against any person who works for the program. d) The disclosure is a requirement of a court order, or of federal or state laws and regulations. e) I am reporting a medical emergency that poses an immediate threat to the health of any individual and requires immediate medical attention. f) I am ordered by a court order, which satisfies the requirements of 42 CFR Part 2. g) I am reporting a crime a patient has committed on the premises of/or against agency personnel. h) I have an executed data sharing agreement for research activity that has been approved by a recognized institutional review board (IRB). I will consult management for direction anytime I am unclear as to the interpretation of confidentiality regulations or the legality of requests made of me for information. I agree to be bound by procedures for safeguarding client information, including: a) All charts, notes, and other written materials will be stored in a secure room or locked up when not in use. b) Discussions regarding clients will be held in staff offices or in other places providing assurance of privacy. c) No privileged information will be shared with other agencies, professionals, friends, or family members without prior written authorization from the patient. d) I will deny requests for access to patient files by anyone not employed by the agency, and refer such requests to the Executive Director. I understand that an unauthorized disclosure of patient information or records may subject me to a civil action for damages of $1,000 or three times the amount of actual damages sustained by a willful release of confidential information under RCW 71.05.440, or state and federal criminal prosecution in accordance with 42 CFR Part 2 and 45 CFR Parts 160 and 164 as follows: 42 CFR Part 2 Penalties • Not more than $500 for the first offense and up to $5,000 for each subsequent offense. 45 CFR, Part 160 and 164 Penalties • $100 civil fine per violation, with a maximum of $25,000 per calendar year for each standard violation. 42 USC §1320d-5(a). • $50,000 maximum criminal fine and up to one year imprisonment if an individual knowingly makes a wrongful disclosure or wrongfully obtains protected information. 42 USC §1320 d.6. • $1,000,000 maximum fine and 5 years imprisonment if offense is committed under false pretenses. • $250,000 maximum fine and 10 years imprisonment if offense is committed with intent to sell, transfer, or use the protected information for commercial advantage, personal gain or malicious harm. I understand my Oath of Confidentiality and these requirements do not cease at the time I terminate my relationship with the company. I agree to be permanently bound by this oath and by the regulations of confidentiality henceforth.