Referring Physicians/Providers Confidentiality Agreement
for access to Online Patient Images/Reports

This Confidentiality Agreement (“Agreement”) is entered into as of, between Imaging Healthcare Specialists, LLC, a California limited liability
company (“IHS”) and (“you”) who intends to be legally bound, agrees as follows:

1. Basis for Agreement. IHS is as a “Covered Entity” under the Health Information Portability and Accountability Act of 1996 (“HIPAA”). Under the HIPAA rules, IHS is required to enter into this Agreement to obtain satisfactory assurances that you, a Business Associate under HIPAA, will appropriately safeguard all confidential information disclosed, created or received by you on behalf of IHS.

2. Use of Confidential Information. You shall use confidential information only as needed to perform your proper duties as a referring physician. Accordingly: (a) you shall only access confidential information for which you have a need to know; (b) you shall not divulge, copy, release, sell, loan, review, alter or destroy any confidential information except as properly authorized by IHS; and (c) you shall not misuse confidential information or engage in activities or practices that could reasonably be expected to result in unauthorized or inadvertent disclosure of confidential information.

3. Disclosure of Confidential Information. You may disclose confidential information you obtain or create as a business associate if (a) such disclosure is required by law and necessary for the proper management and administration of your services; or (b) you obtain reasonable assurances from the recipient that the confidential information shall be held confidentially and shall not be used or further disclosed except as required by law or with such further authorizations required by law, and then only for the purpose for which it was initially disclosed to the recipient, and the recipient agrees in writing to promptly notify you (and you hereby agree to promptly notify IHS) of any unauthorized disclosure.

4. Security Safeguards. You shall implement a documented information security program that includes administrative, technical and physical safeguards designed to prevent the accidental or otherwise unauthorized use or disclosure of confidential information, and the integrity and availability of electronic confidential information you create, receive, maintain or transmit on behalf of IHS. The security program shall include all the reasonable and appropriate policies and procedures to comply with the requirements of the HIPAA “Security Rule” (45 C.F.R. Part 160 and Subparts A and C of Part 164).

5. Unauthorized Disclosure. You accept responsibility for all activities undertaken using your access code and other authorization provided by IHS. You also accept all responsibility for your misuse or wrongful disclosure of confidential information and for your failure to safeguard your access code or other authorization access to confidential information. You agree to indemnify, defend and hold IHS and its directors, officers, employees, representatives, successors and assigns free and harmless from and against all losses, claims, fines, fees, damages, charges or other liabilities sustained by any of such indemnities arising out of or related to your unauthorized disclosure or unauthorized use of confidential information or otherwise arising out of your breach of this Agreement.
Referring Physicians/Providers Confidentiality Agreement
for access to Online Patient Images/Reports

6. Obligations Under The American Recovery and Reinvestment Act of 2009 (ARRA). You agree to the following:
6.1 You shall not disclose confidential information to a health plan if the individual to whom the confidential information pertains has so requested and (a) the disclosure would be for the purposes of payment or health care operations, and not for the purposes of treatment; (b) the protected health information at issue pertains to a health care item or service for which the individual pays out-of-pocket and in full; and (c) the disclosure is not required by law.
6.2 You shall comply with all rules governing marketing communications that encourage the recipient to purchase or use a product or service offered by you.
6.3 You acknowledge you will be held to the same standards as IHS to rectify a pattern or activity or practice that constitutes a material breach or violation of your obligations under this agreement. You will also be subject to the same penalties as a covered entity for any violation of the HIPAA privacy or security requirements, and you will also be subject to periodic audits by the HHS Secretary.
6.4 You shall comply with all rules adopted by the HHS Secretary regarding the sale of confidential information.

7. Disclosure Accounting. If you make any disclosures of confidential information that are subject to the accounting requirements of 45 C.F.R. §164.528, you shall promptly report such disclosures to IHS. Your notice shall include the name of the individual, the recipient, the reason for disclosure and the date of the disclosure. You shall maintain all of the foregoing information in a record of each such disclosure, which record shall also include the address of the recipient of the confidential information and a description of the confidential information disclosed. You shall maintain this record for a period of six (6) years and make available to IHS upon request in an electronic format so that IHS may meet its disclosure accounting obligations under 45 C.F.R. §164.528.

8. Termination. Either party may terminate the Agreement upon provision of thirty (30) days prior written notice, provided that if a party commits a material default of its obligations under this Agreement and fails to cure such default within five (5) days after notice from the non-breaching party, the non-breaching party may terminate this Agreement immediately upon conclusion of the 5-day period.

9. Change in Law. In the event that there are subsequent changes or clarifications of statutes, regulations or rules relating to Agreement, IHS shall notify you of any actions it reasonably deems necessary to comply with such changes, and you shall promptly take such actions. In the event there is a change in the federal or state laws, rules or regulations, or any interpretation or any such law, rule, regulation or general instructions which may render any of the material terms of this Agreement unlawful or unenforceable, or materially affects the financial arrangement contained in this Agreement, either party may, by providing advanced written notice, propose an amendment to this Agreement addressing such issues. If, within fifteen (15) days following the notice, the parties are unable to agree upon such amendments, either party may terminate this Agreement by giving the other party at least thirty (30) days written notice.

By signing this Electronic Signature Acknowledgment of the Imaging Healthcare Specialists, LLC, Confidentiality Agreement, I agree that my electronic signature is the legal equivalent and having the same validity as my handwritten signature. I agree to abide by all conditions as outlined within this document.