Auxiliary Membership Application Packet

Dear Community Member,  

We are excited that you are interested in volunteering at Bay Area Hospital! Volunteers are the heartbeat of our hospital, providing invaluable services and support to our patients. 

Included in this packet for your completion and signature are:

• Auxiliary Application
• Release and Consent Form
• General Authorization 
• Confidentiality Agreement
• Volunteer Commitment and Agreement

Directions:

1. Please complete each section on the application
2. Once completed, select "REVIEW ANSWERS"
3. Scroll pages to review entries, and hit the green "SUBMIT" button
4. Your application will be electronically submitted directly to us

What Happens Next? Once we receive your application, we will contact you to schedule a tour and interview. After the interview, if you are accepted into the Auxiliary, we will need to schedule two Employee Health appointments for you, which are done here at the hospital. This is required for all healthcare workers, so it is good practice. You will go through TB screening and complete another packet of forms.

Once you clear Employee Health, you must attend a two-hour Volunteer General Orientation, which will cover the BAH Auxiliary Volunteer Guide in detail. All volunteers must be interviewed prior to starting and agree to pay a $10 annual fee to offset nominal program costs.

Volunteers provide valuable services to the hospital and our community. We appreciate your interest in volunteering.

Auxiliary Membership Team
Bay Area Hospital
1775 Thompson Road
Coos Bay, OR 97420
(541) 269-8135

Volunteers@bayareahospital.org

I agree to participate in Bay Area Hospital’s Auxiliary. I agree to read the literature that is provided to me so that I will understand the expectations.

I understand that I am required to have a Tuberculosis Test and a Criminal Background Check and I give my permission for these tests to performed. I further understand that if I do not pass the Criminal Background Check, I will be dismissed from the program.

I am aware and acknowledge that during the course of my duties, I might view medical procedures, surgeries, and births. The records are subject to the strictest of confidentiality according to HIPAA Privacy laws. 

I understand that it is my responsibility to find or provide transportation to and from my assignments. I agree to notify the appropriate person in advance if unable to work and that several absences may be grounds for dismissal from the program.

The following is a consent form for you to be photographed while participating in Bay Area Hospital’s Volunteer Program. The pictures are typically used for promotional or communications purposes. There may be situations where we have media coverage of events.

I hereby voluntarily authorize Bay Area Hospital and/or its parent corporations, subsidiaries, affiliates, agents, contractors, providers or employees to interview and/or take photographs of me. I understand that the term “photograph” may include, but is not limited to, videotape, videodisc, digital image and any other mechanical means of recording or producing visual images (hereinafter referred to as “photographs”). I also understand the interview may involve, but not limited to, audio tape, or other recording device, podcast, webcast, blog, written recording or other mechanical means or medium to preserve the discussions (hereinafter referred to as “interview material”).

I understand and agree that the photographs and/or interview material may be used and/or disclosed for any and all purposes deemed appropriate by the Entity above, its parent corporation, subsidiaries and affiliated organizations. Such purposes may include, but not be limited to, education, treatment, public relations, advertising, communication materials, promotional, and marketing publications (including postings on an organization’s website, podcast, webcast, blog), and/or fundraising activities.

I understand that I may refuse to sign this Authorization, that there is no obligation to participate and as applicable treatment, payment, enrollment in any health plan, or eligibility for benefits will not be conditioned upon my providing this Authorization for the use and/or disclosure of my photographs or interview material.

I agree to hold the Entity harmless, and its parent corporation, subsidiaries, affiliates, agents, officers, contractors, providers, directors, and employees, or other third parties designated by these entities or individuals that are involved in the production, duplication, publication, or any other use and/or disclosure of the photographs, and/or interview material for any damages or losses incurred by such use and/or disclosure of the photographs and/or interview material. I also understand the photographs and/or interview material used and/or disclosed pursuant to this Authorization may be re-disclosed by a recipient and such cannot be controlled by any of the aforementioned parties.

In addition, I waive all rights to or conditions on the use and/or disclosure of these photographs and/or interview material that I may have and waive any claim for payment or royalties related to the use and/or disclosure of the photographs or interview material (whether such is for charitable or commercial purpose) by the Entity, its parent corporation, subsidiary, affiliate, or any other party involved in any use and/or disclose now or in the future.

I further understand and agree that these photographs and/or interview material may be used beyond the initial purpose and expiration date, if any listed below, for archival and/or historical purposes by Entity, its parent corporation, subsidiaries or affiliates.

REVOCATION:

I understand that I may revoke this Authorization at any time by notifying Bay Area Hospital in writing by sending a letter to Bay Area Hospital, 1775 Thompson Road, Coos Bay, OR 97420, Attn: Human Resources Department.  I understand that if I revoke this Authorization, it will not affect any actions that Bay Area Hospital took before receiving my revocation letter. If the participant involved is under 18 or unable to grant this Authorization, the Guardian or Legal Representative must provider Authorization. I hereby certify that I am the Volunteer or Legal Representative of the person named above. I do give my Authorization without reservation to the foregoing.

As a user of Bay Area Hospital Information, you may develop, use, or maintain patient information or business information that is confidential.  Bay Area Hospital Information (“BAH Information”) from any source in any form (including paper records, oral communication, audio recordings, and electronic displays) should be kept strictly confidential.  You may access Bay Area Hospital Information only if you need to know the specific Bay Area Hospital Information to perform your job responsibilities.

Violations of Bay Area Hospital’s policies and procedures may include, but are not limited to:

1. Accessing BAH Information that is not within the scope of your job responsibilities to BAH or otherwise permitted by written policy.
2. Accessing health information in a manner inconsistent or contrary to federal or state laws governing health records release such as laboratory test results (for outpatients only) which require a 7-day waiting period before releasing such information to the patient.
3. Leaving patient medical records or charts in an unsecured place, or a portable storage device or mobile application, or leaving a secured application unattended while signed on to the computer system.
4. Misusing, disclosing without proper authorization, or improperly altering BAH Information.
5. Disclosing your sign-on code and/or password or using another person’s sign-on code and/or password for accessing electronic or computerized records.
6. Discussing BAH Information in a public place (e.g., elevator or cafeteria) or with persons not authorized to receive such information.

Employees:

Violation of Bay Area Hospital policies and procedures by employees may lead to corrective action, up to and including termination of employment.

Medical Staff Members:

Violation of Bay Area Hospital policies and procedures by medical staff members may constitute grounds for corrective action, up to and including termination of employment or loss of medical staff privileges, in accordance with applicable Medical Staff Bylaws, Rules, and Regulations. 

Students:

Violation of Bay Area Hospital policies and procedures by students may constitute grounds for corrective action in accordance with applicable BAH or educational institution procedures up to and including termination of affiliation agreement.

Vendors and Other Affiliated (External) Users:

Violation of BAH policies and procedures by third parties, such as temporary staff, vendors, or other authorized users (e.g., external physician office staff), may constitute grounds for corrective action, termination of the user’s access, or termination of the contract or other terms of affiliation.  External users must have a Sponsor.  The sponsoring person is designated as someone who verifies that information submitted on this form is accurate.  The sponsoring person is responsible for submitting updates/changes, including terminations for anyone who they are sponsoring, including the physician for his/her office staff and Clinic name.

Violation of BAH policies and procedures also may result in civil and/or criminal liabilities and penalties.

ACKNOWLEDGMENT

I agree to comply with the terms of this Confidentiality Statement and Agreement Regarding Bay Area Hospital Information.  I agree to comply with Bay Area Hospital Privacy and Security Policies and the Joint Notice of Privacy Practices adopted by Bay Area Hospital as they apply to my position as an student, employee or active member of the medical or allied health staff or other affiliation.  I understand that the obligations set forth in this statement and agreement continue beyond the end of my relationship with Bay Area Hospital.  I understand that I am agreeing to the terms of the Statement and Agreement Regarding Bay Area Hospital Information on my behalf and not on behalf of any other person.

1. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors or personnel, and not seek to obtain confidential information from a patient.

2. I shall submit to tuberculosis (TB) test(s), drug test(s), flu immunization(s), and any other appropriate lab tests or immunizations that may be necessary as part of my volunteer service.

3. I commit to volunteering for at least one school term unless circumstances out of my control prevent me from doing so. I understand I must volunteer at least 4 hours each month to remain an active volunteer in the program.

4. I shall comply with Bay Area Hospital’s Dress Code. I shall wear my badge and appropriate attire while volunteering.

5. My services are donated to the hospital without compensation or future employment, and given with educational, humanitarian, and charitable reasons.

6. I may not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on hospital premises, unless I receive the express authorization of the Volunteer Services Coordinator to engage in these activities.

7. I shall be punctual, conduct myself with dignity, courtesy and consideration of others, and endeavor to make my work professional in quality.

8. I shall make my best effort to fulfill my commitment to Bay Area Hospital by completing all assignments that I accept.

9. I shall at all times uphold the mission and values of Bay Area Hospital.

10. I understand that the Auxiliary Board reserves the right to terminate any volunteer as a result of failure to comply with (1) Bay Area Hospital rules and regulations, or (2) any other circumstances which, in the judgment of the Auxiliary Board, would make any continued services as a volunteer contrary to the best interests of Bay Area Hospital.

11. I understand that Bay Area Hospital assumes no responsibility for any contact, visits or services provided by me outside of the responsibilities assigned through the volunteer program at Bay Area Hospital.

12. Volunteers are NOT covered under Bay Area Hospital’s Medical Insurance should an injury or illness occur while on duty. I also acknowledge the risks associated with working in a hospital environment, where community acquired conditions are possible. Volunteers MUST have their own personal medical insurance during their volunteer service.

13. At the completion of my volunteer service at Bay Area Hospital, I agree to turn in my badge and uniform.