Visitor Statement of Confidentiality

Georgia Department of Behavioral Health & Developmental Disabilities Judy Fitzgerald, Commissioner

Georgia Regional Hospital at Savannah Volunteer Services 1915 Eisenhower Drive, Savannah, Georgia 31406 912-356-2011

I understand that as a visitor on the campus of Georgia Regional Hospital Savannah, I have a responsibility to comply with the confidentiality policy of the Georgia Department of Behavioral Health and Developmental Disabilities which mandates that I cannot reveal whether or not an individual is a client in this institution or disclose any identifiable information concerning a client.

I understand the importance of maintaining confidentiality for all consumers of the mental health/developmental disabilities/addictive disease system and that this right to confidentiality is protected by state and federal laws, Department of Behavioral Health and Developmental Disabilities rules and regulations and Georgia Regional Hospital Savannah policies and procedures.

Visitor Statement of Safety & Security

I understand that the type of items carried on my person may be limited to ensure the safety of consumers, staff and visitors on the hospital grounds. I understand that it is prohibited to give any type of personal items to consumers without proper authorization.

Purpose of my visit to Georgia Regional Hospital Savannah: ______

My signature below indicates my agreement to the requirements of these statements.

______Signature Date

______Print Name Date

Information (912) 356-2011 Hospital Regional Hospital Administrator Hospital Switch Board (912) 356-2045 The Joint Commission dbhdd.georgia.gov/grhs Equal Opportunity Employer