Certificate of Completion

This is to certify that I,

LOPEZ,JESSICA PAMELA
have read, understand or know where to ask
questions about and agree to abide by the
Policies and Procedures associated with the
UCLA OCR Resolution Agreement and I have
completed the required online HIPAA Privacy
and Information Security training for New
Workforce Members on
Wednesday, October 28, 2015
at UCLA Health System

Reference No: 404723525

AppliestoallUCLAHealthSystem"workforcemembers"including:employees,medicalstaffandotherhealthcareprofessionalsvolunteers
agency,temporaryandregistrypersonnelandtrainees,housestaff,students,andinterns(regardlessofwhethertheyareUCLAtraineesor
rotatingthroughUCLAHealthSystemfacilitiesfromanotherinstitution).
ItistheresponsibilityofallUCLAHealthSystemworkforcemembers,asdefinedabove,includingemployees,medicalstaff,housestaff,studentsand
volunteers,topreserveandprotectconfidentialpatient,employeeandbusinessinformation.
ThefederalHealthInsurancePortabilityAccountabilityAct(the"PrivacyRule"),theConfidentialityofMedicalInformationAct(CaliforniaCivilCode 56etseq.)
andtheLantermanPetrisShortAct(CaliforniaWelfare&InstitutionsCode 5000etseq.)governthereleaseofpatientidentifiableinformationbyhospitalsand
otherhealthcareproviders.TheStateInformationPracticesAct(CaliforniaCivilCodesections1798etseq.)governstheacquisitionanduseofdatathat
pertainstoindividuals.Alloftheselawsestablishprotectionstopreservetheconfidentialityofvariousmedicalandpersonalinformationandspecifythatsuch
informationmaynotbedisclosedexceptasauthorizedbylaworthepatientorindividual.
ConfidentialPatientCareInformationincludes:Anyindividuallyidentifiableinformationinpossessionorderivedfromaproviderofhealthcareregardinga
patient'smedicalhistory,mental,orphysicalconditionortreatment,aswellasthepatientsand/ortheirfamilymembersrecords,testresults,conversations,
researchrecordsandfinancialinformation.(Note:thisinformationisdefinedinthePrivacyRuleas"protectedhealthinformation.")Examplesinclude,butarenot
limitedto:
Physicalmedicalandpsychiatricrecordsincludingpaper,photo,video,diagnosticandtherapeuticreports,laboratoryandpathologysamples
Patientinsuranceandbillingrecords
Mainframeanddepartmentbasedcomputerizedpatientdataandalphanumericradiopagermessages
Visualobservationofpatientsreceivingmedicalcareoraccessingservicesand
Verbalinformationprovidedbyoraboutapatient.
ConfidentialEmployeeandBusinessInformationincludes,butisnotlimitedto,thefollowing:
Employeehometelephonenumberandaddress
Spouseorotherrelativenames
SocialSecuritynumberorincometaxwithholdingrecords
Informationrelatedtoevaluationofperformance
OthersuchinformationobtainedfromtheUniversity'srecordswhichifdisclosed,wouldconstituteanunwarrantedinvasionofprivacyor
DisclosureofConfidentialbusinessinformationthatwouldcauseharmtoUCLAHealthSystem.
PeerreviewandriskmanagementactivitiesandinformationareprotectedunderCaliforniaEvidenceCodesection1157andtheattorneyclientprivilege.
Iunderstandandacknowledgethat:

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Ishallrespectandmaintaintheconfidentialityofalldiscussions,deliberations,patientcarerecordsandanyotherinformationgeneratedinconnectionwith
individualpatientcare,riskmanagementand/orpeerreviewactivities.
Itismylegalandethicalresponsibilitytoprotecttheprivacy,confidentialityandsecurityofallmedicalrecords,proprietaryinformationandother
confidentialinformationrelatingtoUCLAHealthSystemanditsaffiliates,includingbusiness,employmentandmedicalinformationrelatingtoourpatients,
members,employeesandhealthcareproviders.
Ishallonlyaccessordisseminatepatientcareinformationintheperformanceofmyassigneddutiesandwhererequiredbyorpermittedbylaw,andina
mannerwhichisconsistentwithofficiallyadoptedpoliciesofUCLAHealthSystem,orwherenoofficiallyadoptedpolicyexists,onlywiththeexpress
approvalofmysupervisorordesignee.Ishallmakenovoluntarydisclosureofanydiscussion,deliberations,patientcarerecordsoranyotherpatientcare,
peerrevieworriskmanagementinformation,excepttopersonsauthorizedtoreceiveitintheconductofUCLAHealthSystemaffairs.
UCLAHealthSystemAdministrationperformsauditsandreviewspatientrecordsinordertoidentifyinappropriateaccess.
MyuserIDisrecordedwhenIaccesselectronicrecordsandthatIamtheonlyoneauthorizedtousemyuserID.UseofmyuserIDismyresponsibility
whetherbymeoranyoneelse.Iwillonlyaccesstheminimumnecessaryinformationtosatisfymyjobroleortheneedoftherequest.
Iagreetodiscussconfidentialinformationonlyintheworkplaceandonlyforjobrelatedpurposesandtonotdiscusssuchinformationoutsideofthework
placeorwithinhearingofotherpeoplewhodonothaveaneedtoknowabouttheinformation.
IunderstandthatanyandallreferencestoHIVtesting,suchasanyclinicaltestorlaboratorytestusedtoidentifyHIV,acomponentofHIV,orantibodies
orantigenstoHIV,arespecificallyprotectedunderlawandunauthorizedreleaseofconfidentialinformationmaymakemesubjecttolegaland/or
disciplinaryaction.
Iunderstandthatthelawspeciallyprotectspsychiatricanddrugabuserecords,andthatunauthorizedreleaseofsuchinformationmaymakemesubjectto
legaland/ordisciplinaryaction.
MyobligationtosafeguardpatientconfidentialitycontinuesaftermyterminationofemploymentwiththeUniversityofCalifornia.

I,LOPEZ,JESSICAPAMELA,certifythaton10/28/2015IhavereadandunderstandtheConfidentialityAgreementandagreetoabidebyit.Intheeventofa
breachorthreatenedbreachoftheConfidentialityAgreement,IacknowledgethattheUniversityofCaliforniamay,asapplicableandasitdeems
appropriate,pursuedisciplinaryactionuptoandincludingmyterminationfromtheUniversityofCalifornia.

Name:

LOPEZ,JESSICAPAMELA

EmployeeID:

404723525

Date:

10/28/2015

PrintName:

Signature: