MEDICAL EDUCATION SERVICES
MEDICAL STUDENT CHECKLIST
STUDENT NAME: _____________________________________________________________________
SCHOOL: ____________________________________________________________________________
SPONSOR: ___________________________________________________________________________
ROTATION: ____________________________________DATES: ________________________________
Professional Headshot of student (no selfies, please)
Contact Information (Email address, Cell phone number, etc.)
Letter from school advising student in good standing
Application completed at least 30 days in advance from start date
Confidentiality statement completed
PPD Status Reporting form completed
Copy of PPD results and other immunizations (Flu, Covid, etc.)
Verification of school’s professional liability insurance coverage
Information Systems Account Creation/Deletion form (only complete highlighted fields)
COMMENTS:
Please return application to the Medical Education Office at Archbold Memorial, 915 Gordon Avenue, Thomasville, GA, 31792
Ph- 229-228-2448 F- 229-584-7154
P a g e | 1
Student Supervised Educational Experience Application
Please complete ALL sections thoroughly and clearly.
Student
Information
Today’s Date:
Name:
DOB:
Mailing Address:
(City, State, Zip)
Email
Address:
Phone
Number:
Emergency Contact:
Phone Number:
Relationship:
A letter from Medical School must be on file in the Medical Education Office prior to beginning your
educational experience. The letter must include the following:
1. Verify you are a student in good standing
2. Approval, naming this specific rotation
3. Specify exact dates of rotation
4. Verify your health status to perform duties requested
5. Professional Liability Coverage Carrier (attach a copy indicating policy number, amount of
coverage and expiration date)
Education Information
School:
Program: MD/DO NP PA
AA OTHER
Clinical
Rotation(s)
Needed
Specialty/ Sponsor
#
of
hours
Start
Date:
(Specific
Date)
Rotation End Date:
(Specific
Date)
P a g e | 2
Check Appropriate Hospital: Archbold Memorial Archbold Brooks
Archbold Grady Archbold Mitchell
Other
Rotation
details:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
__________________
Check the correct answer; attach explanation for any yes answers.
Yes No Have you ever voluntarily or involuntarily been suspended, restricted, or terminated from
Any affiliation or relationship with any school or education facility?
Yes No Have you ever received a formal reprimand or disciplinary action or been the subject of
disciplinary proceedings or investigations at any school, hospital, or health care facility?
Yes No Are any such proceedings in progress?
Yes No Have you ever been charged with a crime other than a non-felony motor vehicle violation?
Yes No Do you have or have you ever had a physical or mental condition (including drug or alcohol
abuse) that could affect your ability to exercise the activities associated with this affiliation or
would require accommodation in order for you to perform activities requested in a safe and
competent manner?
Yes No Do you currently suffer from any communicable disease that could be transmitted to patients
or others?
I understand that in all contacts with patients, family, friends of patients, and staff of Archbold Medical Center
(AMC) that I must wear a name badge and white coat identifying myself as a student. Additionally, I understand
that I must verbally identify myself as a student and obtain oral permission to attend or be involved in the care of
any patient with whom I may be assigned.
I understand that I must be supervised at all times by a physician who is a member in good standing of AMC.
I attest that all information furnished by me is true to the best of my knowledge and furnished in good faith, I
understand that willful and significant omissions or misrepresentation may result in immediate termination of my
affiliation.
I agree to report any changes in my school status or health status that would affect my ability to complete my
affiliation as outlined by my sponsor.
PRINTED NAME ______________________________________________________________________
SIGNATURE ______________________________________________________ DATE _____________
Please return application to the Medical Education Office at Archbold Memorial, 915 Gordon Avenue, Thomasville, GA, 31792
Ph- 229-228-2448 F- 229-584-7154
HW103 10/2023 Page 1 of 2
CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT
WITH EMPLOYEES AND OTHER WORKFORCE MEMBERS OF ARCHBOLD*
As an employee, student, volunteer, or other member of Archbold’s Workforce/Medical Staff, I acknowledge that I have
completed Health Insurance Portability and Accountability Act (“HIPAA”) training and:
1. I understand all patient and business
information, in any format, is confidential, and I will
access and use this information only when necessary
to perform my job-related duties. I will keep such
information confidential. This information includes
but is not limited to clinical treatment, demographic,
billing, financial, and identifiable information also
known as Protected Health Information or “PHI.”
2. I agree to respect and abide by all laws pertaining
to the confidentiality of identifiable medical, personal,
and financial information. I understand that I could be
held civilly and criminally liable (through monetary
fines and/or imprisonment) for improper use or
disclosure of patient personal, financial, or medical
information.
3. I agree to adhere to all Archbold policies and
procedures related to HIPAA including the privacy,
security, use/disclosure of protected health
information and corresponding breach notification
regulations.
4. I will secure my computer workstation at all
times and practice good workstation security
measures by logging out of applications and locking my
workstation when my workstation is unattended. I
understand if I use a workstation that is accessible to
other users, I need to log out of any open applications
before simply locking the workstation. I understand
that, as a requestor of access or user of Archbold's
computer system, my user login ID is the equivalent of
my legal signature, and I will be accountable for all
representations made at login and for all work done
under my login ID.
5. I will safeguard my user login ID and password at all
times. If I believe the security of my login ID and
password has been compromised, I will immediately
change it through the Archweb self- service portal or
contact Information Services at 229-228-2959 to have
my password changed. I understand that Archbold
audits access and use of its computer systems.
6. I understand any security token/FOB used to
remotely access Archbold’s computer systems is to be
used only by me. I am not to give this remote access
token to any other individual.
7. I will not access patient information regarding
myself, family members, or friends. I understand that
I may access my information from Archbold patient
portals or follow established Health Information
Management Department procedures to obtain
information from my medical record—just as any other
patient does.
8. I understand that the misuse of my access to
Archbold’s computer systems (including accessing
my own records, my family/friends' records or
snooping), or of confidential information obtained,
may subject me to disciplinary action up to and
including termination of my access rights or my
employment.
9. I understand I am only to discuss patient
information with other workforce members who need
to know that information to do their job. I understand I
am not to discuss or disclose patient information
outside the organization.
10. I understand specific administrative policies and
procedures exist regarding the release of medical
record information and release of patient condition
information. Only designated individuals may disclose
such information in accordance with specified
procedures in Administrative Policies #105.06, “Release
of Protected Health Information” and #101.02,
“Release of Patient Condition Information.”
11. I understand that my obligation to protect the
confidentiality of patient and business information
extends even after I terminate my employment or
other relationship with Archbold.
12. I understand paper documents, CDs, and any
documents containing PHI are to be placed in secure
shred bins and are not to be discarded in regular trash.
HW103 10/2023 Page 2 of 2
13. I agree not to disclose patient information on any
Internet-based websites or social media websites. I
understand all patient information (even where the
patient's name is not used) is confidential and is not to
be disclosed in any manner to any outside party or to
any workforce member unless that workforce member
needs to know that information to do their job.
14. I understand I am to not capture any image or
recording of a patient on my personal cell
phone/device. Also, I am not to record by audio, video,
camera or cell phone any interactions, meetings, or
other interactions between employees, patients,
family members, physicians, or guests without prior
approval of Administration. If, in the course of my job
responsibilities, my personal cellular device is
authorized for use by Archbold for treatment,
payment, or operational activities, I am only to use it
for designated communication purposes with
designated, secure communication applications for
needed treatment, payment, or operational
communications.
15. I agree not to send, forward, copy, print,
download, remove, or inappropriately disclose PHI
outside Archbold.
16. I agree to encrypt (use “Archsafe”) all outgoing
emails sent for treatment, payment or operational
purposes that contain protected health information. I
understand I am not to email PHI to private email
addresses.
17. I agree I will not save PHI to unencrypted drives,
laptops, CDs, phones, other portable devices, or online
document storage applications including, but not
limited to, DropBox, Google Drive, Amazon WorkDocs,
etc. I understand I am to save business and patient
information to secure network drives and not to my
local workstation drive.
18. I will not alter, destroy, copy, or sell any PHI. I will
only access and use PHI as properly authorized.
19. I understand if I have any questions or concerns
about privacy and security of patient information
and/or the proper use or disclosure of patient
information, I am to discuss these with my Supervisor
or Archbold’s Privacy Officer at 229-228-2928.
20. I understand it is a condition of my job
responsibility to immediately report any and all
potential privacy or security incidents or breaches or
any unauthorized/inappropriate access, use or
disclosure of patient protected health information to
Archbold’s HIPAA Privacy Officer at 229-228-2928, or
Information Services at 229-228-2959.
Signature: _________________________________ Date: _____________________________
Name:____________________________________ Department: ________________________
(Print)
"Archbold" means (1) John D. Archbold Memorial Hospital, Inc., which includes Archbold Memorial, Archbold Grady, Archbold
Brooks, and Archbold Mitchell, and all of their on-campus and off-campus provider-based departments, facilities, rural health clinics,
pharmacies, durable medical equipment provider, hospices; Archbold Northside, Archbold Living Thomasville, Archbold Living Camilla,
Archbold Living Pelham, and Archbold Living Cairo; and (2) Archbold Medical Group, Inc., which owns and operates multiple
physician medical practices. Website www.archbold.org
("Locations" tab) explains more about Archbold locations.
WELCOME TO ARCHBOLD!
MISSION
To Provide the citizens of South Georgia and
North Florida with high-quality, patient-focused healthcare in a cost effective-
manner.
VISION
To be the Best Healthcare System in the region.
VALUES
Quality · Patient Experience · Financial Stewardship Community Benefit ·
Growth · Employee Satisfaction
CODE OF ETHICS
Our hospital's code of ethics directs that all patient care and business concerns
are conducted in an ethical manner consistent with our
mission, vision and
values.
MAINTAINING PATIENT CONFIDENTIALITY
Archbold Medical Center is committed to the privacy of our patients and the security of their health and personal information
at all times.
It is the policy of Archbold Medical Center to comply with the privacy and security requirements of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
As an individual taking part in an educational opportunity, you must adhere to these requirements. You should not access any
information about a patient that is not required as part of your role. In the course of performing duties, you may come in
contact with patient information and materials which are highly confidential. Information, records or materials concerning
patient information may not be used, released, or discussed with anyone who is not involved in the care of the patient.
Patient's health information is the property of the Medical Center and must be carefully maintained to serve the patient, the
healthcare providers and the Medical Center in accordance with legal, accrediting and regulatory agency requirements. All
patient care information must be regarded as confidential and available only to authorized users.
All incoming calls and inquiries concerning a patient's condition must be referred to an employee authorized to handle such
requests. Never discuss any information about a patient in elevators, corridors, the cafeteria, or at any other location where
you may be overheard by others.
MEDIA
If you are approached by the media (a representative from a television or radio station, newspaper, etc.) you should refer them
immediately to the Marketing and Public Relations Department at 584-5520. You should not answer any questions or make
any comments to the media.
INFECTION CONTROL
Definitions
Infection: the entry and multiplication of a disease producing germ (an infections agent) in the tissues of a host (person).
Mode of transmission: the manner in which an infectious agent is transferred to the host. Commonly, on healthcare workers'
hands or on contaminated equipment inadequately disinfected between patient contacts.
Prevention interventions: the measures used to control or eliminate the infectious agent and to interrupt its transmission to a
new host.
Blood/body fluid exposure: any contaminated needle stick or sharps injury, splash or spray of blood/body fluids into eyes, nose,
or mouth, or contamination of non intact skin (scratch, dermatitis, laceration) with blood/body fluids.
Prevention Interventions
Standard Precautions: policy to prevent exposures to the blood and/or body fluids of ALL patients.
Hand washing: the single most important control measure for preventing the spread of infection. Use soap, paper towels and
running water routinely.
Gloves: the use of gloves does NOT replace hand washing. Wear gloves whenever touching blood/body fluids, no-intact skin,
mucous membranes, or contaminated items/surfaces. DISCARD AFTER USEAND WASH YOUR HANDS.
INFECTION CONTROL - CONTINUED
When to wash with soap and water:
• When hands look dirty
• When hands feel dirty
• After contamination - known/possible - by body secretions or excretions; especially after using the bathroom, coughing,
sneezing or wiping the nose.
• Before eating or handling food
• When caring for or visiting sick people
• After handling money
When washing hands, please remember the following:
• Remove jewelry and push up sleeves
• Turn on water and adjust temperature
• Dispense soap
• Lather thoroughly and with vigor for 10-15 seconds
• Rinse well
• Dry hands with paper towel
• Now turn off water with towel
• Dispose of towel without touching waste container
• Use hand lotion to prevent chapping
When to use alcohol hand sanitizer
Anytime hands are not visibly soiled, but you know that you have touched something that is not clean.
INFECTION CONTROL - CONTINUED
Cough Etiquette
• Cover your cough or sneeze with a tissue. If one is not available, cough or sneeze into your elbow.
• Dispose of tissues properly
• Wash your hands after handling soiled tissues or coughing or sneezing into your hands.
Transmission-based isolation precautions:
DO NOT ENTER THE ROOMS OF PATIENTS ON ANY OF THE FOLLOWING:
• Airborne precautions - Blue Sign (e.g., chickenpox or tuberculosis)
• Droplet precautions - Green Sign
• Contact isolation - Yellow Sign (e.g., draining wounds or MRSA)
• Strict isolation - Tan Sign
SAFETY/EMERGENCY PREPAREDNESS
Safety and emergency preparedness is of utmost importance at the Medical Center. Listed below are the emergency codes used.
Should you be here when a code is called, immediately find your supervisor/preceptor or a staff member and do as you are told.
Code Black Bomb Threat
If there is a true bomb emergency, the hospital operator will announce "Code Black" 3 times followed by instructions.
Code Blue
Code Blue Peds CPR
These codes are used when a cardiac or respiratory arrest occurs. Code Blue indicates adult and Code Blue Ped indicates pediatric.
All of our staff have been trained in CPR and the proper response in the hospital setting. The hospital operator will announce
"Code Blue and the location of the victim 3 times. (Code Blue room 101)" If you are in a patient's room or alone with a patient, and
the patient has no pulse or respiration, notify someone in charge immediately to determine if the patient is a "No Code". If not,
CPR should be initiated immediately and the code protocol activated. This is done by dialing 6 on the nearest telephone and
advising the operator of the exact location of the incident. Each area has a "crash cart" specifically stocked for code situations. An
ambu bag and code kit is located on the top of these carts. Please locate them and become familiar with them. The quicker the
CPR is administered the better the outcome for the patient. Please remain in your designated
area during this event.
Code Decon Decontamination
Many materials found in the community and hospital can be health hazards if not managed properly. There are many
governmental regulations that require safe handling, transportation, use and storage of these materials. The hospital has also
taken action to reduce the threat of an internal hazardous materials exposure by limiting the amounts of chemicals stored at the
facility and within the departments. In light of these regulations and safe practices, accidents will occur. The hospital trains staff
members working with hazardous materials in proper utilization and handling, thus decreasing the likelihood of an incident
within the hospital.
Code Green
Manpower Needed
The Code Green Emergency Call System is established to provide help to personnel for assisting with the care of patients and
their families. Code Green is a twenty four (24) hour emergency code to be used only in the situation where by the hospital
personnel in the immediate area needs assistance with a client such as lifting or moving a client, and in extreme cases the physical
health of the person or others is in danger or where for some other impelling reason extra manpower is needed immediately.
Mitigation for manpower assistance is difficult; however, the hospital has purchased equipment to assist staff in lifting patients.
A Code Green may be called after an unruly patient overwhelms security staff and additional assistance is needed. The hospital has a close
relationship with local law enforcement to provide assistance as needed.
Code Grey Violent Event
Violence is random and unpredictable. This makes mitigation of these events difficult if not impossible. Through increased overall security, staff
alertness and observations the risk can be lessened. Limited access doors are in areas of higher risk with general video monitoring of the facility.
Additionally, we have a visible presence of security officers roving the facility and campus.
Code Lockdown Secure the Building
It is the policy of this facility to provide a safe environment for our patients and visitors. Code Lock-Down will be announced to alert hospital staff in
the event the Hospital needs to be secured to prevent unauthorized entry or exit.
Code Orange Hazardous Materials
Many materials found in the community and hospital can be health hazards if not managed properly. There are many governmental regulations
that require safe handling, transportation, use and storage of these materials. The hospital has also taken action to reduce the threat of an internal
hazardous materials exposure by limiting the amounts of chemicals stored at the facility and within the departments. In light of these regulations
and safe practices, accidents will occur. The hospital trains staff members working with hazardous materials in proper utilization and handling, thus
decreasing the likelihood of an incident within the hospital.
Code Pink Infant Abduction
Used for a child up to the age of 12 years old is kidnapped. The operator will announce, "Code Pink: followed by the age and the sex of the child.
(ex. Code Pink, zero, female) Upon activation of this code all hospital entrances and exits are closed and no one is allowed in or out of the building
until "Code Pink all clear" has been announced 3 times by the operator. During this event, all staff members will be searching for a person with an
infant or child fitting the description given of the victim. If the victim is an infant or small child, any and all items that are of sufficient size to
conceal the child will also be searched. Please remain in your clinical area until the "Code
Pink all clear" has been announced.
Code Red Fire
This is the code for fire or smoke, one of the most life threatening situations that can occur in any health care facility. Every hospital employee
receives fire safety education on an annual basis as well as frequently conducted drills. There is a good possibility that you will be here during a
drill. The hospital operator will announce "Code Red" and the location 3 times. The staff will ask patients and visitors to remain in the patient's room
with the door closed. If you are leaving any area of the hospital when the announcement is made DO NOT GET ON AN ELEVATOR and DO NOT
WALK THROUGH CLOSED FIRE DOORS, remain where you are. Should you discover a fire, DO NOT SHOUT FIRE. Remove people from the room or
immediate vicinity, close the door and pull the fire alarm. Once the fire has been contained and no danger exits, the hospital operator will
announce "Code Red all clear" 3 times. Please look for the fire alarm boxes and fire extinguishers wherever you are in the hospital.
Code Triage Triage
This code is used in the event of a disaster. Our hospital has a disaster plan designed to provide care for a large number of people.
Twice a year the hospital conducts a disaster drill. Each department and nursing unit is assigned certain duties, such as setting up a
first aid station. The hospital operator will announce "Code Triage" 3 times followed by an explanation and instructions for visitors and
hospital staff.
Code Weather Severe Weather
Thunderstorm warning, tornado watch, tornado warnings.
My signature below indicates that I have read and understand this orientation packet.
I have had the opportunity to ask questions and have had the questions answered to my satisfaction.
I understand that I am responsible for following the procedures outlined in this orientation packet.
SIGNATURE DATE
ARCHBOLD MEDICAL CENTER
P. O. Box 1018
Thomasville GA 31799-1018
AMH
BCH
GGH
MCH
TB RISK ASSESSMENT AND SYMPTOM EVALUATION
Please answer all of the following questions:
TB Hi
story
Have you had a positive TB test or PPD in the past?
Yes No
TB Risk Assessment
Temporary or permanent residence for greater than one month in a country with a
high TB rate? This includes any country other than the United States, Canada,
Australia, New Zealand, and those in Northern or Western Europe?
YES
NO
Current or planned immunosuppression, including human immunodeficiency virus
(HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist
(e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone >
15mg/day for > one month) or other immunosuppressive medication?
YES
NO
Close contact with someone who has had infectious TB disease since your last TB
test?
YES
NO
TB Symptom Evaluation
Have you been experiencing any of the following symptoms?
Unexplained fever
YES NO
Coughing for longer than 3 weeks
YES
NO
Coughing up blood
YES
NO
Unexplained fatigue or tired feeling
YES
NO
Loss of appetite
YES
NO
Unexpected weight loss
YES
NO
Shortness of breath
YES
NO
Pains in chest
YES
NO
**For annual screening, an employee with a YES to “Coughing for longer than 3 weeks” and
one other symptom should be referred to Corporate Care for evaluation and clearance.
Employee Signature:__________________________________________ Date:______________
Form Reviewed By:___________________________________________ Date:_____________
Name: ___________________________________ Employee #: __________________Date: _____________
HR240 08/19
ARCHBOLD REGIONAL HEALTH SYSTEM
STUDENT – PPD/TST STATUS REPORTING
NAME: ________________________________________
(Print or Type)
TB Skin Test: ____________________________________________
Results Date
My TB test converted to positive ______________
Year
My last chest x-ray was ____________________ and the results were ___________.
Date
My personal physician following this is _____________________________________.
1. Persons with a positive TST must submit a copy of a recent baseline chest radiograph within one (1)
month to exclude diagnosis of TB.
2. Individuals who have had a previous positive TST MUST NOT be tested again. Please answer
questions below.
TB Symptom Screen (Previous Positive TST)
Have you been having any of these symptoms? Please Circle
Unexplained fever YES NO
Coughing for longer than 3 weeks YES NO
Coughing up blood or excessive mucus YES NO
Unexplained fatigue or tired feeling YES NO
Loss of appetite YES NO
Unexpected weight loss YES NO
Shortness of breath YES NO
Pains in chest YES NO
Sweat excessively at night YES NO
_________________________________ ___________________
Signature Date
History of a previous positive TST test or documentation of significant allergic response is the only
contraindications for TST skin testing. Pregnancy is not a contraindication for administration of a TST skin
test.
Archbold Regional Health System Medical Staff Policy TST Status Reporting #18
ARCHBOLD MEDICAL CENTER
P. O. Box 1018 • Thomasville, GA 31799-1018
STUDENT/INSTRUCTOR/NURSING RE-ENTRY CLINICAL CLEARANCE FORM
Route request to Departmental Clinical Contact
*****Please allow 2 WEEKS for account creation*****
Creation of user name only applies for one semester/quarter. A new request must be submitted each
quarter/semester unless otherwise arranged.
Please check one of the following: New account (If an Instructor provide DOB______________)
Returning Student/Instructor username: _________________
Correct Existing Account (please describe correction needed)
Account Deletion/Inactivation (mid quarter/semester dismissal only)
Computer/System access requested: NO access needed Soarian Clinicals MAK (Med Admin)
Student Full Name: ______________________________________________________________________
(Please print) First Middle Last
Middle Initial and ID# MUST
be included before a login can be issued
Student contact number: _________________________________________________________________
Student ID: School: _________________________________________________
Hospital Orientation Date _____/_____/_____ Computer Orientation Date: _____/_____/_____
Instructor’s Name, Phone #, & E-mail: _____________________________________________________
Rotation Dates - Start: _____/_____/_____ End: _____/_____/_____
Course of Study: (Please check one): Clinical Rotation Preceptorship, if yes,
Assigned Preceptor Name: ________________________________ Unit: ________ Shift: _____________
RN LPN Respiratory Radiology Surgery Lab Business Office Cardio Tech
Dietetics Pharmacy Medical Student Other: _______________________________
Therapy (select one): Physical Occupational Speech Recreational
Nursing Re-Entry (NOTE: A copy of your nursing permit is required)
Facility/Site(s): __________________________________ Dept/ Unit(s): __________________________
By signing this form, I, the instructor, certify the student is current with the following REQUIRED
clinical clearance items through this semester/quarter, check all that apply (includes Archbold employees):
BLS (American Heart) HIPAA Training Current Immunizations Flu Shot (during Flu Season)
Student Liability Insurance current Student orientation completed/date to be completed: _______.
Orientation packet completed & signed if unable to attend orientation
PPD Date completed - _____/_____/_____. PPD neg. ( PPD pos. / Previous pos. / (follow-up required))
Within 2 yrs after school’s admission date:
Drug screening - ( Negative/ Positive/(results submitted to coordinator))
Background Check completed by Pre-Check & submitted to Archbold’s student coordinator for approval.
If Pre-Check was not
used for the background check, a copy MUST accompany this form
Instructor’s Signature Date Student’s Signature
Special accommodations (e.g. Latex Free): ____________________________________________________________________
____________________________________________________________________________________________________________________
IS 112-1 07/13
ARCHBOLD MEDICAL CENTER
P. O. Box 1018 • Thomasville, GA 31799-1018
STUDENT CONFIDENTIALITY AND NON-DISCLOSURE STATEMENT
All information pertaining to patient records, condition, personal details, and computer security is confidential.
User names and passwords are not to be shared with anyone. Student is not to use his/her access to get
information on patients or employees outside the student’s direct care.
I, ____________________________________________________, a student/instructor in clinical rotation at
Archbold Medical Center, acknowledge that I have reviewed and understand the policies set forth below. I
have read, signed and agreed to abide by the Archbold Medical Center’s Confidentiality Statement.
• I understand that all patient information in any format, including billing and financial data, is
confidential.
• I agree to keep patient information confidential.
• I understand that my computer login ID is the equivalent of my legal signature, and I will be accountable
for all representations made at login and for all work done under by login ID. I understand that data
and information stored in the Medical Center’s computer systems is confidential patient, financial, and
organizational information, and I must treat it with the same care as data and information in paper
records.
• I will safeguard my computer login ID and password at all times. If I believe the security of my login ID
and password has been compromised, I will immediately contact my instructor.
• I agree to comply with all Health System Privacy Policies and Procedures including those implementing
the HIPAA privacy rule. I understand specific policies and procedures exist regarding the release of
medical record information and release of patient condition information. Such information is to be
disclosed only by designated individuals and in accordance with specified procedures in
Administrative Policies #105.06, “Release of Medical Record Information” and #101.02, “Release of
Patient Condition Information.”
• I understand that I will not access information regarding myself, family members, friends, patients,
fellow students, employees, or members of the medical staff, unless it is relevant to the performance
of my clinical rotation. I understand that I am to follow established Medical Record Department
procedures to obtain clinical information from my individual medical record just as any other patient
does.
• I understand if I have any question or concerns about the Privacy Rule and /or the proper use of the
disclosure of patient information, I should ask my Instructor or clinical supervisor or the Medical
Center’s Privacy Officer/Compliance Officer.
• I understand and agree that the Health System Privacy Policies and Procedures will apply to any patient
information I have access to at the Health System even after I complete my rotation or other
relationship with Archbold Medical Center.
Student Signature: ________________________________________________ Date:
______________________
(Please Print)
Name: __________________________________________________ School: _______________________________
IS 112-2 07/13
ARCHBOLD
MEDICAL
CENTER
ADMINISTRATIVE
POLICY
MANUAL
SUBJECT:
Release
of
Patient
Condition
Information
APPROVED:
President
POLICY
NUMBER:
101.02
EFFECTIVE:
January
1992
EXPIRES:
When
Superseded
REVIEWED:
January
2021
REVISED:
January
2021
I.
POLICY
It
is
the
policy
of
Archbold
Medical
Center
(AMC)
to
hold
patient
medical
information
in
the
strictest
confidence,
releasing
only
that
information,
within
the
law,
which
provides
adequate
representation
of
the
patient's
condition
and
only
as
a
response
to
inquiries
about
the
patient.
For
the
purpose
of
this
policy,
patients
are
divided
into
two
categories
-
private
patients
and
cases
for
public
record.
II.
PURPOSE
Patient
condition
information
is
considered
part
of
the
patient's
medical
record
and
may
only
be
released
in
accordance
with
the
law
and
proper
authorization
to
protect
the
patient
from
unauthorized
disclosure
of
patient
medical
information
and
the
hospital
from
the
implications
of
unauthorized
disclosure
of
patient
medical
information.
III.
SPECIAL
INSTRUCTIONS
A.
Private
Patients
1.
Private
patients
are
identified
as
admissions
(other
than
cases
of
public
record:
mental
patients,
drug
or
alcohol
patients,
assault
victims
and
minors)
in
the
Inpatient,
Emergency
Department
and
other
outpatient
departments.
a
Under
ordinary
circumstances,
acknowledgement
of
a
patient's
admission
may
be
made
without
the
patient's
permission;
and
the
general
condition
(not
diagnosis)
can
be
stated.
However,
the
patient
has
the
right
to
specifically
request
his/her
admission
not
be
reported
to
the
news
media
or
the
inquiring
public.
2
General
Condition
of
the
Patient
a
If
confined
to
very
general
terms,
i.e.,
good,
fair,
serious,
undetermined,
this
information
may
be
released
by
the
hospital.
Any
request
for
more
specific
information,
if
a
worthy
request,
will
be
referred
to
the
patient's
family.
Such
information
may
be
released
by
the
hospital
only
if
a
SUBJECT:
Release
of
Patient
Condition
Information
POLICY
101.02
signed
Authorization
for
Disclosure
of
Protected
Health
Information
Form
MR
107
has
been
given
by
the
patient.
3.
Guidelines
for
Determination
of
Patient
Condition
a
Good
-
Vital
signs
are
stable.
Patient
is
conscious
and
comfortable.
b.
Fair
-
Vital
signs
are
stable.
Patient
is
conscious.
Patient
is
uncomfortable
or
may
have
minor
complications.
c.
Serious
-
Vital
signs
may
be
stable
or
not
within
normal
limits.
Patient
is
acutely
ill;
indications
are
questionable.
d
Undetermined
-
This
is
not
a
medical
classification.
It
is
to
indicate
the
patient
is
in
evaluation
process
to
determine
a
more
definite
condition
status.
4.
Pictures
a
When
newspapers,
law
enforcement
officials
or
others
request
the
privilege
of
photographing
any
patient
in
the
hospital
or
on
the
hospital
grounds,
follow
guidelines
in
Policy
#101.57
Photography,
Audio
Recordings,
or
Video
Recordings
of
Patient
Data.
B.
Cases
of
Public
Record
1.
Cases
of
public
record
are
those
involving
the
police,
an
accident,
coroner's
case,
fire
department,
poisoning,
etc.,
or
any
case
which
is
reportable
to
a
government
unit.
2
Police
and
Accident
Cases:
The
following
items
of
public
information
may
be
given
without
the
patient's
consent:
(a)
name,
(b)
address,
and
(c)
general
condition
(good,
fair,
serious,
undetermined)
as
defined
in
paragraph
IIl-A-3
above.
However,
no
specific
reference
to
type
of
injury,
diagnoses,
treatment,
etc.
is
to
be
disclosed.
a
Nature
of
Accident.
May
not
be
stated.
Refer
to
legal
authorities.
b.
Attending
physician.
May
not
be
stated.
c.
Condition
of
patient.
The
general
condition
(not
diagnosis)
may
be
stated
if
confined
to
the
terms
listed
above.
Requests
for
more
than
this
routine
information
must
be
referred
to
the
patient
and/or
his
family
or
the
proper
legal
authority.
d
Fractures.
If
there
is
a
fracture
it
will
not
be
described
in
any
way.
e.
Head
injuries.
There
will
be
no
mention
of
head
injuries.
2
SUBJECT:
Release
of
Patient
Condition
Information
POLICY
101.02
t
Internal
injuries.
There
will
be
no
reference
to
internal
injuries.
g.
Shooting
or
stabbing.
No
statement
may
be
made.
h.
Unconsciousness.
No
statement
may
be
made.
L
Bums.
No
statement
may
be
made.
3.
Dmg
or
Alcohol
Intoxication.
No
information
of
any
kind
may
be
released.
4.
Poisoning.
No
information
of
any
kind
may
be
released.
5.
Sexual
Assault.
No
information
of
any
kind
may
be
released.
6.
Suicide
or
Attempted
Suicide.
No
information
of
any
kind
may
be
released.
7.
Death.
Death
of
a
patient
is
presumed
to
be
a
matter
of
public
record
and
may
be
released
by
the
hospital
after
the
next
of
kin
has
been
notified.
8.
Mental
Patients.
No
information
of
any
kind
may
be
released.
9.
Child
Abuse.
No
information
of
any
kind
may
be
released.
10.
Minors.
No
information
of
any
kind
may
be
released.
Minors
are
considered
to
be
any
patient
age
17
and
under.
C.
Birth
Announcements
Permission
to
announce
the
birth
of
a
baby
must
be
obtained
in
writing
from
the
mother
prior
to
the
announcement
being
made
to
the
news
media.
D.
Community
Disasters
1.
The
hospital
will
make
every
effort
to
keep
the
news
media
informed.
1
Provision
is
made
in
the
hospital
disaster
plan
for
a
press
information
center
supervised
by
Hospital
Emergency
Operations
Plan
for
the
Public
Information
Officer
who
serves
as
the
point
of
contact
to
assist
in
tracking
patients
and
providing
information
to
families
and
for
all
community
and
media
communications
regarding
event
status
and
progress.
3.
All
information
released
will
be
in
accordance
with
this
policy
herein
stated.
E.
News
Gathering
Equipment
Permission
for
utilization
of
news
gathering
equipment
may
only
be
authorized
by
the
President
or
Assistant
Vice
President
of
Marketing.
News
gathering
equipment
will
not
be
utilized
when
it
will
interfere
with
patient
care
or
proper
operation
of
the
hospital.
SUBJECT:
Release
of
Patient
Condition
Information
POLICY
101.02
Information
regarding
photographing
patients
is
covered
under
III-A-4
of
this
policy.
F.
Coroner's
Case
No
information
may
be
released
about
coroner's
cases.
A
coroner's
case
is
indicated
if
any
of
the
following
questions
could
be
answered
"yes."
1.
Was
death
due
to
suicide?
2
Was
death
due
to
suspected
foul
play
or
violence?
3.
Was
the
victim
a
casualty
of
an
accident
such
as
an
auto
wreck,
bums,
fall,
etc.?
4.
Was
the
patient
a
prisoner
when
brought
to
the
hospital?
5.
Did
the
patient
die
within
24
hours
of
admission?
6.
Did
the
patient
die
in
any
suspicious
or
unusual
manner?
7.
Was
patient
admitted
due
to
a
fractured
hip
or
suffered
a
fractured
hip
during
hospitalization?
8.
Was
the
patient
under
seven
(7)
years
of
age
(excluding
newboms)?
G.
Notable
Persons
Notable
persons
are
people
whose
presence
in
the
hospital
would
be
of
considerable
interest
to
the
general
public
and
news
media.
Such
persons
might
include
public
officials,
elected
or
appointed,
and
others
prominent
in
the
community.
Information
conceming
notable
persons
will
be
released
according
to
Section
III-A,
Private
Patients.
IV.
INSTRUCTIONS
FOR
HANDLING
MEDIA
INQUIRIES
Members
of
the
media
frequently
inquire
about
the
status
of
a
patient,
typically
one
requiring
trauma
care
or
relevant
to
some
larger
news
story.
Any
information
to
be
released
to
the
media
regarding
a
patient's
condition
will
be
channeled
through
the
Marketing
Department.
Any
inquiries
from
the
media
received
by
other
departments/areas
are
to
be
directed
to
Marketing.
In
the
absence
of
the
Marketing
Department
staff,
information
for
the
news
media
should
be
provided,
when
possible,
by
the
President,
Senior
Vice
President,
Vice
President
of
Administrative
Services,
Vice
President
of
Patient
Care
Services,
Nursing
Supervisor,
Director
of
Emergency
Department
or
Emergency
Department
charge
nurse.
A.
Procedures
for
handling
media
inquiries:
1.
When
a
patient
is
brought
to
John
D.
Archbold
Memorial
Hospital
(JDAMH)
or
SUBJECT:
Release
of
Patient
Condition
Information
POLICY
101.02
any
system
hospital,
Marketing
is
to
be
called
first.
For
JDAMH,
Marketing
will
contact
the
Nursing
Supervisor.
For
system
hospitals,
the
Director
of
Nursing
will
be
contacted.
Marketing
will
identify
his/her
self
and
ask
for
the
patient
location
and
a
one
word
condition
(good,
fair,
serious,
undetermined)
report
to
release
to
the
media.
Use
code
word
"101.02"
to
assure
the
nursing
staff
it
is
alright
to
release
the
condition.
Marketing
will
relay
only
the
one-word
condition
back
to
the
media.
2
If
the
media
tries
to
get
more
information
or
details,
they
are
to
be
told
that
the
hospital
policy
is
to
only
release
one
of
four
conditions.
3.
Refer
back
to
AMC
Policy
101.02
to
determine
how
to
convey
the
information
you're
about
to
release.
DO
NOT
DEVIATE
FROM
THESCRIPT.
V.
JOHN
D.
ARCHBOLD
MEMORIAL
HOSPITAL,
INC.
(INCLUDING
OPERATIONS
D/B/A
BROOKS
COUNTY
HOSPITAL,
GRADY
GENERAL
HOSPITAL,
MITCHELL
COUNTY
HOSPITAL,
GLENNMOR
NURSING
HOME,
MITCHELL
CONVALESCENT
CENTER,
PELHAM
PARKWAY
NURSING
HOME/ARCHBOLD
FOUNDATION,
INC./ARCHBOLD
HEALTH
SERVICES,
INC./ARCHBOLD
MEDICAL
ENTERPRISES,
INC./ARCHBOLD
MEDICAL
GROUP,
INC.
A.
As
applicable.
ARCHBOLD MEDICAL CENTER POLICY NUMBER: 800.07
SUBJECT: COVID-19 Vaccination Policy
EFFECTIVE: 11/15/2021
EXPIRES: When Superseded
APPROVED:
Vice President of Human Resources
REVIEWED: Annually
REVISED: 6/1/2022
I. POLICY
Archbold Medical Center will comply with the Centers for Medicare and Medicaid (CMS)
Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule requiring hospitals
and other healthcare facilities to vaccinate all staff and applicable individuals with an
approved COVID-19 vaccine by the dates specified in the final rule.
This policy is subject to change at any time as dictated by immediate circumstances or
changes in governmental regulations.
II. PURPOSE
To maintain a safe facility for our patients, employees, medical staff, volunteers, and visitors
as well as to comply with Federal regulations.
III. REGULATORY CITATION
42 CFR 418.60 (Hospice); 482.42 (Hospitals); 483.80 (Long Term Care Facilities); 484.70 (Home Health
Agencies); 485.640 (Critical Access Hospitals); 491.8 (Rural Health Clinics)
[CMS-3415-IFC]
IV. PROCEDURES
A. The following individuals (regardless of clinical responsibility) are covered by this
mandate:
1. Clinical and non-clinical employees
2. Physicians and other licensed practitioners who admit or treat patients in our
facilities
3. Students, trainees, and volunteers
4. Individuals who provide care, treatment, or other non-clinical services at our
facilities or for our patients under contract or other arrangements.
B. Individuals not covered by the mandate:
1. Staff who exclusively provide telehealth or telemedicine services outside of
Archbold and who do not have any direct contact with patients or other staff
members
2. Staff who provide support services for Archbold who perform exclusively
outside our facilities and who do not have direct contact with patients or other
staff.
SUBJECT: COVID Vaccine Policy
POLICY 800.07
2
C. Exemptions. Archbold will engage in an interactive process to determine if a
reasonable accommodation can be provided. Individuals requesting an exemption
must use the forms included in this policy. All questions must be answered, and no
other forms will be accepted.
1. Medical
a. Staff members requesting an exemption due to medical contraindications
must provide proof of medical complication via a written letter from a
physician or other qualified healthcare provider that has current details of
the medical contraindication. This letter needs to specify the allergy
testing that was completed, if any; documentation of anaphylaxis post
vaccination in the emergency room; documentation of Guillain-Barre
syndrome if for the COVID-19 vaccine, or other contraindications that are
recognized by the Centers for Disease Control and Prevention. Requests
should be submitted to the Human Resources Department by the deadline
set by Archbold Medical Center consistent with the recommendations of the
Centers for Disease Control and Prevention. This deadline may vary from
year to year. Individuals who have been extended an offer of employment
must seek an exemption prior to beginning employment if their employment
start date is after the deadline established by Archbold Medical Center.
Staff may request an exemption at any time before the deadline.
b. Only evidence-based medical contraindications against vaccination
confirmed by healthcare providers will be accepted as an exception to the
mandatory vaccination requirement.
c. If exemption is granted for a temporary health condition, a new request
for exemption must be made each year to which the condition applies. If
exemption is granted for a permanent condition, the exemption does not
need to be requested each year unless vaccine technology would change
or eliminate issues regarding allergies.
d. Must complete and submit HR Form 250 - Request for Medical
Exemption from COVID-19 Vaccination and have your medical provider
complete HR Form 249 then submit both forms to the Human Resources
Department.. Provider based forms may suffice and will be reviewed on a
case by case basis.
2. Religious
a. Religious exemption requests will be considered for required COVID-19
vaccinations, and such exemption requests will be managed by Human
Resources. Exemption to a required vaccination may be granted based on
an individual’s religious beliefs. For purposes of this policy, “religious
SUBJECT: COVID Vaccine Policy
POLICY 800.07
3
beliefs” include those that are theistic, as well as non-theistic moral or
ethical beliefs as to what is right and wrong which are sincerely held with
the strength of traditional religious views. Personal preferences do not
constitute religious beliefs.
Staff requesting an exemption due to religious beliefs must complete the
Request for Religious Exemption form by the deadline. Individuals who
have been extended an offer of employment or other staff assignment
must seek an exemption prior to beginning service if their start date is
after the deadline. Staff may request an exemption at any time before the
deadline. Staff will have to provide valid documentation of their religious
faith outlining the specific faith-based concerns against vaccination.
Requests for exemption due to religious beliefs will be evaluated by Human
Resources applying standards established in Title VII of the Civil Rights
Act of 1964 and/or applicable state and local laws relating to religious
accommodations in the workplace. Responses to timely requests for
religious exemption should be provided, via email, within five business days
of the date they are presented to Human Resources. Additional information
may be requested if necessary to adequately evaluate a request for religious
exemption. In such cases, responses should be provided, in writing, within 5
business days or prior to the deadline.
b. The staff member will be notified via email regarding the status of her or
his religious exemption request.
c. Must complete and submit HR Form 248 - Request for Religious
Exemption from COVID-19 Vaccination – to the Human Resources
Department.
3. Accommodations
Individuals who receive an exemption may be required to comply with one or
more of the following:
a. Additional PPE requirements
b. Temporary reassignment
c. Employees may be placed on a leave of absence with or without
the use of PTO
d. If no accommodation is available then employees may have to be
terminated from employment
e. Weekly COVID-19 testing.
D. Tracking and Monitoring
1. Archbold will track the vaccine status of all employees and applicable individuals
through the Disease Management Department.
SUBJECT: COVID Vaccine Policy
POLICY 800.07
4
2. Employees and applicants will submit their vaccination cards or exemption request
to Human Resources. Cards will be sent to Disease Management to be checked
against applicable database and entered into our employee health system.
3. Employees and applicable individuals who receive the vaccine from a provider other
than Archbold are to provide that documentation promptly.
4. Contract staff exemptions are the responsibility of the contract company. They must
provide a list showing both fully vaccinated and exempt staff when requested.
Contractors abide by our policy on vaccine status.
E. Required Compliance Date
1. All individuals covered by this mandate must provide proof of vaccination with
their first shot of any of the approved vaccines (Moderna, Pfizer, or Johnson and
Johnson) or have an approved exemption by February 14, 2022.
2. All individuals covered by this mandate must be fully vaccinated or have an
approved exemption by March 15, 2022.
3. Staff who are currently on a leave of absence beyond the dates above must submit
proof of vaccination before returning to work.
4. No one will be able to start or continue to work until fully vaccinated or approved
for an exemption. This would include new hires. Current employees would be
placed on suspension until fully vaccinated.
V. JOHN D. ARCHBOLD MEMORIAL HOSPITAL, INC. (INCLUDING OPERATIONS
D/B/A BROOKS COUNTY HOSPITAL, GRADY GENERAL HOSPITAL, MITCHELL
COUNTY HOSPITAL, GLENN-MOR NURSING HOME, MITCHELL
CONVALESCENT CENTER, PELHAM PARKWAY NURSING HOME)/ARCHBOLD
FOUNDATION, INC./ARCHBOLD HEALTH SERVICES, INC./ARCHBOLD MEDICAL
ENTERPRISES, INC./ARCHBOLD MEDICAL GROUP, INC.
A. No changes.
SUBJECT: COVID Vaccine Policy
POLICY 800.07
5
Request for Religious Exemption from COVID-19 Vaccination
Name:
Employee Number:
Department:
Job Title:
Date of Employment:
Explain in your own words why you are requesting this exemption.
Describe the moral, ethical or religious principles that guide your objection to immunization.
Are you opposed to all immunizations? If not, please describe the moral, ethical or religious basis
that prohibits particular immunizations.
Have you received any vaccinations in the last five years?
If yes, when?
If yes, what vaccines?
I hereby affirm the truthfulness of this statement.
Signature:
Date:
SUBJECT: COVID Vaccine Policy
POLICY 800.07
6
HR 248 11/21
SUBJECT: COVID Vaccine Policy
POLICY 800.07
7
Request for Medical Exemption from COVID-19 Vaccination
Name:
Employee Number:
Department:
Job Title:
Date of Employment:
Explain in your own words why you are requesting this exemption.
Provide the attached correspondence to your medical provider and return with your exemption
request.
I hereby affirm the truthfulness of this statement.
Signature:
Date:
HR 250 11/21
SUBJECT: COVID Vaccine Policy
POLICY 800.07
7
ARCHBOLD MEDICAL CENTER
P.O.Box 1018 * Thomasville, GA 31799-1018
Dear Medical Provider,
Archbold Medical Center requires vaccination against COVID-19 as a condition of employment
and as required by federal regulation. The individual named above is seeking an exemption to this
policy due to medical contraindications. Medical contraindications and precautions for
immunization should be based on the most recent recommendations of the Advisory Committee on
Immunization Practices/CDC.
Please complete this form to assist Archbold Medical Center in the reasonable accommodation
process.
It is my medical opinion that the person named above should not receive any of the
following COVID-19 vaccinations, Pfizer, Moderna, or Johnson and Johnson due to:
Severe allergic reaction (e.g. anaphylaxis) after a previous dose or close to a vaccine
component. Please provide the dates of allergy testing and the results of such testing:
Other (explain, attach additional sheets as necessary):
This exemption should be:
Temporary, expiring on: / / , or when
Permanent
I certify the above information to be true and accurate, and request exemption from the COVID-19
vaccination for the above-named individual.
Medical Provider Name (print):
Medical Provider Signature:
Date:
Practice Name & Address:
Provider Phone:
HR 249 11/21
SUBJECT: COVID Vaccine Policy
POLICY 800.07
8
EXEMPTION REVIEW
PROCESS
1. Exemption forms will be submitted to HR for review
2. If forms meet basic exemption criteria then HR will notify the staff member
3. If there is a question about the form it will be reviewed by Senior Management to determine next steps*
4. If Senior Management approves then HR will notify the staff member
5. If Senior Management does not approve then form(s) will be returned to staff member for clarification
6. If staff member resubmits their form it will be reviewed again and either approved or denied
*Senior Management may reach out to the Medical Staff Office for assistance in reviewing medical exemption
STUDENT PRECEPTORS – HIPAA CHECKLIST FOR STUDENT ORIENTATION
Make sure all student clearance paperwork (IS-112) is complete, signed, and on file within
the department.
Forward requests for student user access to Information Services
(ISAccessRequest@archbold.org) so that each student receives their own user ID and
password for each rotation.
• No one is to share their user ID/login information with anyone.
• All computer access is to be under the student’s login ID at all times.
During the initial orientation with the student, ask the student to confirm they actually read
and understand each bulleted item on the Student Confidentiality and Non-Disclosure
Statement. (Page two of Form IS-112.)
Confirm that the student has received HIPAA education. If not, the student must receive
it. The Healthstream HIPAA Privacy and Security course assigned to all employees is a
resource. They can also contact Archbold’s Privacy Officer at 228-2928 or
[email protected].
Even if the student verbalizes they are familiar with HIPAA, emphasize the importance of:
o protecting patient privacy;
o realizing the student’s obligation to protect patient privacy and the information they
access during their rotation lasts forever—even after their student rotation ends;
o avoiding any situations through social media, group messages, snap-chat, friends,
fellow students, coworkers, etc. where the student may inadvertently disclose
patient information;
o not taking pictures, video, or any recordings of patients on their cell phone/mobile
device;
o not texting any patient information;
o not copying or removing any patient medical records from the facility; and
o remembering they can be individually liable for HIPAA violations—which can result
in civil and criminal penalties. (Civil means money; criminal means jail.)
If the student will have any case studies or class assignments, the instructor is to assign the
type of patient scenario, diagnoses, treatment, etc. The student is to provide that
assignment criteria to the Director of Health Information Management who will select an
applicable patient encounter for the assignment. The student may not make the selection
themselves from family, friends, etc., they know personally who may meet the assignment
criteria.
IS Confidentiality Agreement for Computer Use
Applicant’s Name
(Please print. F
irst, Middle Initial, Last)
Emp. ID:
Vendor / Dept. Date of Birth:
I agree to keep patient information confidential by observing the following:
1. I will protect my pass
word from use or theft by others.
[ mm/dd/yyyy ]
2. I will sign off/log
off the system when I leave the workstation and not allow others to use my access.
3. I will only look up information on patients for whom I have direct responsibility. I will not look up my own
medical information on the computer.
4. I will share patient information only with people who have a right to access the information in order to perform
their job function.
5. When sharing information with people who have a right to access the information in order to perform their job
function, I will ensure that I am in a private setting where others cannot hear or see the confidential
information.
6. I will follow all Hospital and department rules of conduct whenever I use e-mail.
7. I will password protect any mobile device that contains patient (or confidential) information.
8. I will not disseminate confidential patient information from non-Hospital supported computer/device
without appropriate authorization for release of information.
9. I will dispose of confidential information properly in accordance with all applicable policies.
10. I understand that audits will be performed on computer usage to ensure compliance with all computer related
policies and this confidential agreement.
11. I will follow other specific confidentiality rules for special situations. When departments have standards more
stringent than this statement, I will abide by their standards.
12. I will comply with the enterprise electronic signature policies and protect my electronic signature when issued
to me from use or theft by others.
13. I understand that my employer has the right to take disciplinary action up to and including
termination of my employment for breaches of confidentiality. I acknowledge that I have
read and agree that violation of policies and procedures may lead up to disciplinary action,
including termination.
Signature
Date
This form is kept on file with Colquitt Regional Medical Center Information System Security.