PCI DSS Acknowledgement Form

  • As a member of Lister Healthcare Corporation, I acknowledge that in the course of my employment I may have access to personal, proprietary, transaction-specific, and/or otherwise confidential data concerning staff, patients, and/or other persons through the processing of credit card transactions.  As an individual with responsibilities for processing, storing and/or transmitting credit card data, I may have direct access to sensitive and confidential information in paper or electronic format.  To protect the integrity and the security of the systems and processes as well as the personal and proprietary data of those to whom LHCC provides service and preserve and maximize the effectiveness of LHCC’s resources, I agree to the following:

    • I will utilize credit card data for LHCC business purposes only.
    • I will uphold the LHCC Code of Conduct, available in the compliance manual, and I agree to abide by it.
    • I have been provided a copy of the LHCC’s PCI DSS Policy regarding the proper storing, protection, and disposal of such confidential data and I will ensure that any such data is shredded or otherwise disposed of as per approved office policy when no longer needed.
    • I have read, understand, and agree to abide by the PCI DSS Policy.  Any violations to this policy will be grounds for disciplinary action up to and including termination of employment from LHCC.
  • Date Format: MM slash DD slash YYYY