Municipality of __________________

It shall be the policy of the Town of ______________________________ to have employees engaged in administering the municipality's General Assistance (hereinafter GA) program maintain in strictest confidence client information. In an effort to effectuate compliance, it is the policy of this municipality to have employees engaged in GA functions sign the following agreement.

The undersigned ______________________________, hereby agrees to maintain strict confidentiality relative to all records, papers, files and communications relating to a GA applicant or recipient made or received by persons charged with administering the municipal GA program. No information relating to a person who is an applicant or recipient may be disclosed to the general public, unless expressly permitted in writing by that person. In addition the following shall also apply:

Requests for release of medical information made by GA clients regarding information found in client files shall be made in writing, using appropriate medical release forms. No medical information shall be released without a proper written medical release signed by the GA client.

III. HIV Infection Status Information:

It shall be the policy of this municipality’s GA office not to make mention nor store information relative to a client’s HIV antibody status in client files or records. In the event that HIV status information has been recorded in Municipal GA files, under no circumstances shall the HIV status information be released without obtaining both a written general medical release in addition to a specific HIV information release signed by the GA client requesting release of HIV status information.

Employees found to have acted in violation of this policy/agreement shall be subject to disciplinary action.

___________________________________ Dated: _______________________
(Print Employee Name)

___________________________________
(Employee Signature)

WITNESS:

____________________________________ Dated: _______________________

Legal References: 22 MRSA §4306