Form Center

2. Lenawee County Health Department Confidentiality Agreement

   The LCHD has a legal and ethical responsibility to maintain client privacy, including obligations to protect the confidentiality of client information and to safeguard the privacy of client information including, but not limited to, client medical records and other individually identifiable health information.

4. In addition, I understand that during the course of my employment/assignment/affiliation at the LCHD, I may see or hear other confidential information such as a client's financial data and/or operational information pertaining to the organization that the LCHD is obligated to maintain as confidential.
6. My signature below acknowledges that I have received, read, and understand the LCHD Confidentiality Policy for Employees and Non-Employees and that I agree to abide by the terms outlined in the policy.
8. Electronic Signature Agreement*

   By checking the "I agree" box below, you agree and acknowledge that 1) your document will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

   1. I agree.
10. Electronic Signature*
11. Date*
    Date
13. Position/Job Title*
15. Phone Number*
17. Email Address*
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field