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4People Case Management System
 Case Manager Agreement

Case Manager/ Caseworker Confidentiality Agreement

Case Manager/Caseworker Confidentiality Agreement Printout

Are you a member of a Virtual Agency? (i.e: Home Base, Kids Connect, Partnership etc.) Yes No
If Yes, Please tell us the name of your Agency:

 I understand that in the course of working or volunteering for the Virtual Agency  or Agency listed below:

Agency Name: Phone: Address:

City: State: Zip:   E-Mail:

 

Agency Point of Contact/Director  Phone: Address:

City: State: Zip:   E-Mail:

I may have access to personal information regarding individuals and/or families seeking or receiving services.

I agree that I shall not disclose to anyone, including co-workers or volunteers, for any purpose not related to assistance, any such information without permission from and the respective individual’s prior written permission, or as may otherwise be required by law.

I also agree to comply with the agency or 4People policies that all contacts with the media must be referred to the Director of the Agency. I will not make any disclosures to the media on behalf of 4People or Agency listed above, or governmental agencies unless specifically asked to do so by the Agency Director or 4People.

          By submitting this form I agree to all of the terms listed above.

Caseworker Name: Agency Phone: Agency Address:

City: State: Zip:   E-Mail:

Alternate E-Mail (In Case of Emergency/Disaster):

I Agree constitutes signature) I do not Agree

Once you submit this agreement a preview screen will come up. If all of the information is correct, please print and place in caseworkers file BEFORE final submission.

          

Revision 11/13/06