Member of the Clergy Disclosure Statement

The Health Information Protection and Accountability Act of 1996 (HIPAA) prohibits the use and disclosure of protected health information without a patient’s authorization unless an exception exists.

HIPAA contains an exception for members of the Clergy. Specifically, unless a patient has opted out, the hospital may disclose a patient’s name, room number and religious affiliation to a member of the Clergy.

By accepting this Disclosure Statement, I agree to the following

  1. I am the senior member of my church who has been designated to receive the patient directory information consistent with HIPAA.
  2. I will not share my password with any other individual.
  3. I will not print or republish this patient directory.