Common use of CONFIDENTIALITY OF RECORD Clause in Contracts

CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Signature Information Full Printed Name Title Provider Signature Telephone Date Regional Center Approval of Enrollment Full Printed Name Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional Center

CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Signature Information Full Printed Name Title E-mail address (please print clearly) Provider Signature Telephone Date Regional Center Approval of Enrollment Full Printed Name Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional CenterDate

CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Administrator Signature Information Full Printed Administrator Name (Please print) Title Provider Administrator Signature Telephone Email Address Date Regional Center Approval Confirmation of Enrollment Full Printed Name (Regional Center Use Only) Profile Created by Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional CenterApproved by Title Date

CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Signature Information Full Printed Name Title Provider Signature Telephone Date Regional Center Approval of Enrollment Full Printed Name Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional CenterCenter Please email directly to Vendorization at

CONFIDENTIALITY OF RECORD. The Provider agrees to provide adequate precautions to protect the confidentiality of Consumer information in accordance with Welfare and Institutions Code section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information. Provider Signature Information Full Printed Name Title E-mail address Provider Signature Telephone Date Regional Center Approval of Enrollment Full Printed Name Title Approver’s Signature Telephone Date Return Provider Agreement to the Regional CenterDate