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C-1 A P P E N D I X C Sample Appeal Committee Member Confidentiality Agreement Non-Disclosure Agreement [from Capital Metro, Austin, TX] I agree that I will not, without express written consent of Capital Metro and the party filing the appeal, remove any document, information or other material distributed during this appeal meeting. I also agree that I will not photograph, video tape or otherwise record or reproduce any information which may be disclosed to me during this meeting. I further agree to hold in strictest confidence any protected health information which is disclosed to me and to refrain from discussing such private information or protected health information, as defined by the HIPAA Act of 1996 or other applicable laws and regulations with anyone without the express approval of Capital Metro and the party filing the appeal. Signature line Date Witness #1 Date Witness #2 Date
