Republic of the Philippines

CITY GOVERNMENT OF BUTUAN

Butuan Medical Center
Km. 5 Baan Highway, Butuan City

NON-DISCLOSURE and CONFIDENTIALITY AGREEMENT

for Butuan Medical Center (BMC) Affiliates/ Volunteers/ /Trainees
The Data Privacy Act of 2012, also known as RA 10173, oversees the safeguarding of both your rights
and the rights of data subjects concerning the collection, processing, sharing, and disclosure of personal and
sensitive information. This legislation was enacted to ensure the confidentiality, integrity, and accessibility of
a range of personal and sensitive data, including health-related information. Such data is only permissible for
processing or disclosure under the legal framework or with the explicit informed consent of the individual
patient or data subject involved.

I, ________________________________________________, a _____________________________ of
___________________________________
Name Position Name of Institution

and a ___________________________________ at BMC, fully understand and voluntarily agree to all of the following:
Status

1. I recognize both my rights to data privacy and the rights of my data subjects;
2. I will be exposed to confidential and privileged information during my term at BMC and I agree to keep all
information in strict confidence and will not use, keep, share, disclose or disseminate any
confidential/privileged information that I may be exposed to and I understand that I am obliged to
maintain such confidentiality at all times even after I am no longer connected with BMC;
3. As a BMC affiliate/volunteer/trainee, I must act as a trustee, guarding the confidentiality, integrity,
availability accuracy accessibility and security of all health information with which I am entrusted.
Additionally, I shall exercise the same care when handling information concerning other clients that I
may come into contact with;
4. I understand that all the medical information/records regarding a patient are confidential. This may also
be true for other clients of BMC;
4.1. I shall no share nor give this information to other entity/ies or individual/s;
4.2. I understand that it is not appropriate to discuss any patients care/treatment/information in
public places or with people who have not been involved in the case or have no reason to know
about this information.
5. All documents encompassing confidential patient or client information that are within my possession
whether in written, graphic, magnetic, digital, photographs, videos, or other format on my personal
gadgets/hard drives, personal computer, electronic tape or hard copies, shall be surrendered to BMC at
the end of my affiliating/ volunteering/ training without restraining any copies for myself, my institution
or other entity/persons;
6. I understand that any deviation from the aforementioned guidelines could potentially lead to legal
actions being taken against both my institution/organization and myself.
7. I further understand that any breach or potential or threat of breach of confidentiality, whether
intentional or unintentional may result in immediate termination of my affiliation status with and my
institution/organization will be duly informed.

By signing below, I affirm that I have received a comprehensive explanation of all the confidentiality
aspects aforementioned, and I have given a chance to seek clarification through inquiries. I understand the
importance of data privacy and the protection of the confidentiality of patient, client or hospital related data.

I have read this Non-Disclosure and Confidentiality Agreement and understood the foregoing
information, and I am aware that by affixing my name and signature below, signifies that I agree and
explicitly give my consent to comply with and abide by the above terms and conditions of my own free will
and volition.

_______________________________________
Printed Name & Signature

Date: ________________________________
Phone: N/A
Email: hospitaldirector.bmc@gmail.com
Website: http://www.butuan.gov.ph