Employee Name (full):

    Address:

    City:

    State:

    ZIP:

    Mobile Number:

    I understand that my signature indicates that I will not share the following information with anyone outside of the Southern Therapy Solutions staff:
    - Names of patients
    - Ages of patients
    - Diagnoses of patients
    - Photos of patients
    - Any and all things pertaining to patients
    I understand that it is my responsibility to handle any confidential information, and that am I am restricted from accessing, inspecting, using, and disclosing, confidential information beyond the STS staff.

    Document(s):

    HIPPA Confidentiality Agreement