Patient Confidentiality Agreement

A patient confidentiality agreement is an agreement which is made between a patient and the doctor in which the doctor keeps the information of the patient confidential. The agreement lays down the certain terms and conditions which have to be followed in order to complete a successful agreement.

Sample Patient Confidentiality Agreement:

This agreement is made between PROVIDER and RECIPIENT hereby the PATIENT and the DOCTOR respectively.

The effective date of agreement: 28th Dec, 2010

Details of the RECIPIENT

Name: Dr., Mathew Jobs

Clinic Address: DY7, hill road, LA

Contact number: 44689347984

Details of the PROVIDER

Name: Miss Olivia Field

Address: FR-9, first floor, Ridge Street, LA

Contact number: 47329844749

Terms and conditions:

  • The provider hereby agrees to share all the information regarding her treatment, financial details, personal information etc… with the recipient.
  • The recipient agrees to keep all the information confidential till the expiry of the agreement which is after 12 months from the effective date.
  • In case any party violates the terms of the agreement, then it shall be held punishable under law of breach of contract.
  • The recipient shall only use the information provided for evaluation purposes and would not share it with any third party or individual.


Matthew Jobs                 Olivia Field

Category: Confidentiality Agreements

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