STUDENT JOB SHADOWING AGREEMENT
The undersigned enter into this STUDENT JOB SHADOWING AGREEMENT (the “Agreement”) between Atlanta Dental Center, LLC and Atlanta Dental Center, PC (collectively, “ADC”), and {name} (“Student”), effective the date signed below by Student.
As part of ADC’s effort to promote dental careers, it allows students to participate in job shadowing. The student must agree to the following requirements:
1. Generally, job shadowing consists of observing various clinical roles for a short duration, from a few hours to a few days.
2. The Student will comply with all policies and requirements of ADC. The Student recognizes and agrees that ADC shall have the right to refuse the use of the facility to the Student if ADC determines, in its sole discretion that the Student's behavior or performance is disruptive, inappropriate, insubordinate, inadequate or a potential threat to the welfare of patients, staff or for other reasons in the sole discretion of the manager of any department.
3. The Student recognizes and agrees that the Student will not be considered an employee of ADC for any purpose whatsoever and that there is no contract of hire or apprenticeship, express or implied, between the Student and ADC and no employer-employee relationship between ADC and the Student.
4. The Student will receive no payment or compensation from ADC and has no expectation of any payment or compensation.
5. Before participating in the program, the student must be free from all communicable diseases and be up to date on all shots.
6. The Student hereby understands and agrees that neither ADC nor its employees, assignees, nor its subsidiaries may be held liable, in any way, for any occurrence in connection with my participation on ADC’s premises which may result in injury, death or other damages to me or my family, heirs or assignees. I acknowledge that certain risks are inherent in participating in a program at a dental office or in a healthcare setting. These include, but are not limited to, the risks of personal injury, illness or death, negligent acts or omissions of the Student or others, including ADC. The Student expressly and voluntarily assumes all such risks.
7. As a Student with access to confidential information, the Student is required to conduct him/herself in strict conformance with applicable laws and ADC policies regarding confidential information. The Student’s principal obligations in this area are explained below:
a. Confidential Information means documents and shall include written and other tangible materials containing health information, medical records, conversations, billing information, financial information, demographic information, employment information of patients at ADC, its affiliates and other affiliated health care providers.
b. Use of Confidential Information - Student shall not disclose such confidential information for any purpose or any reason other than in the active treatment of patient, in conjunction with the legitimate and authorized functions of the Program (i.e., quality assurance, medical education, medical teaching and medical research) or other instances where specific written authorization has been provided (i.e., third party payor utilization review).
c. Access to Confidential Information - Student shall take appropriate measures to assure the confidentiality and security of any information accessed by Student. Confidentiality applies to both computerized records, paper records and all other forms of recordation (i.e., x-ray films, models, etc.).
d. Duration - Student’s obligation of confidentiality as expressed herein shall extend perpetually and shall survive Student’s participation in the Program.
e. Student Obligation.
i. Student agrees that the patients have legal rights under both federal and state law regarding their personal privacy and confidentiality of their medical information.
ii. Student agrees that he/she is responsible for maintaining and safeguarding patient information.
iii. Student agrees not to discuss his/her involvement in the treatment of any patient, whether a friend, relative or stranger, with any individual, including other students, employees, or members of the medical staff, except for a) the active treatment of a patient, b) express authorization by the patient, c) a legitimate and authorized education function, medical research or d) instances where specific written authorization has been provided.
iv. Student also agrees not to use the computer access to view patient confidential information records on any patients (whether a colleague, friend, family member or employee of ADC and its subsidiaries) unless Student is actively involved in the patient’s treatment, has express authorization from the patient or is reviewing the records pursuant to a legitimate and authorized medical staff function or other instances where specific written authorization has been provided.
v. Student understands that ADC and its subsidiaries operates a tobacco free facility and will abide by the policy.
vi. Student agrees to comply with OSHA Standards including safety and infection control.
vii. Student represents that he/she has not been disbarred or sanctioned by Medicare or Medicaid.
viii. Student understands and agrees that he/she is prohibited from placing information about patients, staff, and employees of ADC on blogs, web pages, social media and other electronic media (e.g. MySpace, etc.).
ix. Student understands that if he/she violates any of the above, Student will be terminated from the program.
8. Student and ADC expressly agree that the covenants and agreements contained in this Agreement are independent, separate, severable, and divisible, and in the event any portion or portions of such paragraphs are declared invalid or unenforceable, the validity of the remaining paragraphs of this Agreement will not be affected. If any provision contained herein shall for any reason be held excessively broad or unreasonable as to time, territory, activity, services, or interest to be protected or otherwise unenforceable, the court is hereby empowered and requested to modify such provision by narrowing it, so as to make it reasonable and enforceable to the extent provided under applicable law.