I, *, acknowledge that employees/providers of Area Ambulance Service collect personal and confidential information verbally, in writing, and through digital means. I understand and agree that any information pertaining to patients is strictly confidential and protected by federal and state laws. I will not use or disclose patient information in any way unless Area Ambulance Service authorizes me to do so. 

I agree that I will comply with all HIPAA policies and procedures in place at Area Ambulance Service during my experience as a guest/student with Area Ambulance Service. If at any time I knowingly or inadvertently breach patient confidentiality or violate the HIPAA policies and procedures of Area Ambulance Service, I agree to notify Area Ambulance Service immediately. 

I also understand that I may be exposed to other confidential or proprietary information of Area Ambulance Service, and I agree not to reveal any of that information to anyone at any time unless I am authorized by Area Ambulance Service to do so. This means that I will not disclose information about Area Ambulance Service’s business practices or other information that Area Ambulance Service might consider to be confidential or proprietary. 

Failure to uphold these obligations may result in immediate suspension or termination of the privilege to gain clinical experience or observe the activities of Area Ambulance Service. Upon termination of this privilege for any reason or at any time upon request, I agree to return any and all patient information or confidential or proprietary information in my possession. I understand that any patient or confidential information that I see or hear while a guest or student will stay here at Area Ambulance Service when I leave. 

I have been given an overview of Area Ambulance Service’s HIPAA policies and procedures and have been given access to review those policies, and I agree to abide by them. 

Printed Name:  *

Signature:  *

Date:  *