Erlanger Observation Privilege Request Form

Erlanger Privacy and Confidentiality

During your observation to our facility, efforts will be made to prevent incidental disclosure of protected health information (PHI); however, in observing activities that use PHI you may unintentionally see clinical, financial, and/or demographic information belonging to our patients. You must hold such information in strict confidence. It you are directly observing a specific case the attending physician and/or Nurse Manager will be responsible for assuming that the patient is informed end authorizes your observation to their care/treatment.

Also the direct patient observation will be reported to the Privacy Officer so that such direct observation of confidential patient information is recorded in the accounting of disclosures log as required by Federal Privacy Regulations.

You can assist this hosting facility in preventing incidental disclosures by:

a) Staying within the department or work areas included in the site visit/observation;

b) Standing an appropriate distance from computer screens which contain PHI (i.e. allowing you to view the process, but not enabling you to read patient information);

c) Avoiding areas where patient specific information is discussed and could be overheard, unless so authorized by the specific patient; Using test patient data for up-close review of application screens;

d) Reporting to the Privacy Officer opportunities to further enhance the protection of PHI during site visits/observation. Your assistance by volunteering is important for community service and is often important for introduction of health care to potential career choices.

Observation is invaluable to the improvement of healthcare operations and educational opportunities.

By signing this agreement, I attest that I understand the importance of maintaining patient privacy and confidentiality and I agree to hold in confidence any protected health information directly via patient authorization incidentally disclosed to me during my participation in this site visit/observation.

I agree to assist Erlanger in preventing incidental disclosures by following the guidelines listed above.

Further, I understand that intentional violations of patient confidentiality will result in a report to the Office of Civil Rights and may subject me to the hospital's disciplinary policies, civil and/or criminal liability.

Erlanger Liability Waiver

I (the Participant) understand and acknowledge that, in exercising Observation Privileges at Erlanger, I will be exposed to the normal risks of any hospital visitor, as well as additional risks that may arise due to being in patient care areas and observing patient care, and I voluntarily assume these risks.

In the event of exposure to blood or other bodily fluids from a patient who is a carrier of, or is at risk of carrying, a contagious or infectious disease, Erlanger may administer immediate precautionary treatment to me consistent with current medical practice without any further consent from me, and I agree that I am financially responsible for any such treatment resulting from an exposure. Erlanger shall have no responsibility for any further diagnosis, medication, or treatment, and

I acknowledge and assume the risk of observing or being in the immediate presence of patients at risk of carrying a contagious or infectious disease. With full knowledge of these risks, I hereby release, waive, and discharge Erlanger, and its directors, officers, agents, affiliates, employees, representatives, successors, and assigns (Erlanger Releasees) from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death that I may sustain while exercising my Observation Privileges.

I understand and acknowledge that the scope of my Observation Privileges at Erlanger are limited and that I am strictly prohibited from engaging in any activity inconsistent with the terms or scope of my Observation Privileges, and I agree to abide by the terms of the Observation Privileges. I further agree to indemnify, defend, and hold harmless the Erlanger Releasees from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising, directly or indirectly, from any and all claims made by or against any of the Erlanger Releasees due to injury, loss, or death from or related to any conduct or activity inconsistent with or outside the scope of my Observation Privileges.