SAINT FRANCIS DOCTORS’ HOSPITAL AND MEDICAL CENTER
NURSING SERVICE DEPARTMENT
Masterson Avenue, Upper Canitoan, Cagayan de Oro City, 9000
Emergency Room: 09171437001 │ Ambulance: 09171478001 │ Information: 09171837001
Email address:
[email protected] /
[email protected] NON-DISCLOSURE AGREEMENT
This non-disclosure Agreement is entered into by and between SAINT FRANCIS DOCTORS’ HOSPITAL AND
MEDICAL CENTER and the undersigned Clinical Instructor and/or Student. This agreement establishes the
obligations of the Clinical Instructor and/or Student concerning the confidentiality of patient information and other
sensitive information encountered during their clinical exposure at the facility.
Effective Date: _________________
1. CONFIDENTIAL INFORMATION
For the purpose of this Agreement, “Confidential Information” includes, but not limited to:
Patient health information (including medical records, diagnoses, treatment plans, and any other
health-related data).
Any information related to the Facility’s operations, policies, procedures, or business practices
that is not publicly available.
Any information obtained during the clinical exposure period that is deemed confidential by the
facility.
2. OBLIGATIONS OF THE CLINICAL INSTRUCTOR AND/ OR STUDENT
The Clinical Instructor and/ or Student agrees to the following:
Confidentiality of Patient Information:
o The Clinical Instructor and/or Student will not disclose, share, or otherwise use any
Confidential Information for any purpose other than the delivery of healthcare services
as part of the educational training program. The confidential information will be sued
only as necessary to perform their duties and responsibilities within the scope of their
clinical exposure.
No Unauthorized Access:
o The Clinical Instructor and/ or Student will not access patient information unless
involved in the care if the patient or authorized by the nursing staff, or appropriate
facility personnel. The Clinical Instructor and/or Student will not seek out information
unrelated to their educational tasks.
No Photographs or Recordings:
o The Clinical Instructor and/or Student will not take photographs, videos, or make
recordings of any kind of patient or patient-related information during clinical exposure
without explicit written consent form the patient and in accordance with the facility.
Protection of Information:
o The Clinical Instructor and/or Student will take appropriate steps to protect the
confidentiality and security of any patient information they may have access to. This
include safeguarding physical documents and ensuring that any electronic devices
containing confidential information are kept secure.
Disclosure Limitations:
o The Clinical Instructor and/or student shall not disclose any confidential information to
any third parties, including family members, friends, or other individuals, without the
express written consent of the patient or as required by law.
SAINT FRANCIS DOCTORS’ HOSPITAL AND MEDICAL CENTER
NURSING SERVICE DEPARTMENT
Masterson Avenue, Upper Canitoan, Cagayan de Oro City, 9000
Emergency Room: 09171437001 │ Ambulance: 09171478001 │ Information: 09171837001
Email address: [email protected] / [email protected]
3. DURATION OF CONFIDENTIALITY OBLIGATION
The confidentiality obligations outlined in this agreement will remain in effect for the duration of the
Clinical Instructor’s or Student’s participation in the clinical exposure and will continue indefinitely
even after the completion of the program.
4. BREACH OF AGREEMENT
Any breach of this agreement by the Clinical Instructor and/or Student, including unauthorized
disclosure of Confidential Information, will be treated as a serio9us violation of both ethical standards
and facility policy. Breaches may result in immediate disciplinary action, including termination of the
training program, removal from the facility, and legal consequences.
5. RETURN OF INFORMATION
Upon completion of the clinical exposure, the Clinical Instructor and/ or Student agrees to return or
destroy any physical or electronic copies of Confidential Information, patient records, or sensitive
information that they may have obtained during their time at the facility.
6. LEGAL COMPLIANCE
The Clinical Instructor and/ or Student agrees to comply with all applicable regulations regarding
patient confidentiality, including, but not limited to:
o Data Privacy Act of the Philippines (RA 10173)
o Any other local and national privacy and confidentiality laws
By signing this Agreement, the Clinical Instructor and/ or Student acknowledges that they have read,
understood, and agree to the terms and conditions of this Agreement. They also acknowledge that violation of this
Agreement may result in serious consequences, including termination of their clinical training program and legal
action, as necessary.
SIGNATURES
Name of Clinical Instructor/ Student : ________________________________________
Signature : ________________________________________
Date : _______________________________________
Nursing Service Director : JOHN TROY C. GAMIL, MN, RN
Signature : _______________________________________
Date : _______________________________________
