Download Fox Cities Community Health Center - Tri

Tri County Community Dental Clinic
Confidentiality Statement
As an employee of, or volunteer/student at, Tri County Community Dental Clinic, I
understand that I will come in contact with confidential patient and business information.
This information may be about the clients we serve, staff, volunteers, or business matters.
I agree not to divulge this information to anyone other than Health Center staff on a need
to know basis during or after my employment.
I certify that I have read and understand this Confidentiality Statement and agree to abide
by the policies and procedures Tri County Community Dental Clinic. I understand that
failure to comply with the Confidentiality Statement may lead to disciplinary action up to
and including termination of employment or clinical experience at Tri County
Community Dental Clinic.
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Print Name
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Signature
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Date