I certify that all information contained in this request for job shadowing is true to the best of my knowledge and belief. I agree that any misleading or false statements would render this request void and would be sufficient cause of immediate disapproval of my request or subsequent removal from the Job Shadowing Program.

I certify that I have reviewed the Shadowing Agreement and agree to abide by all standards and expectations contained in the agreement.

If accepted to shadow, I shall release, indemnify, and hold harmless GVH, GVH-owned clinics, their directors, employees, and representatives, from and against any and all responsibility and obligation for my participation in job shadowing. I agree to not hold GVH liable for any or all injuries, losses, damages, or expenses which may occur as a result of any act or omission of GVH, their directors, employees, or representative or which may arise from my participation in job shadowing.

If under 18 years of age, signature of parent or legal guardian is required.

As an observer at Gunnison Valley Health you may have access to confidential information including protected health information (PHI) obtained through your association with one or more of these entities. The purpose of this Agreement is to help you understand your personal obligation regarding confidential information.

 Confidential information, including protected health information (PHI), business asset data, secret, proprietary, or private information is valuable and sensitive and is protected by law and by strict confidentiality policies. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), establishes standards for the protection of patient information. The HITECH Act addresses the privacy and security concerns associated with the electronic transmission of health information.

 As a condition of and in consideration of my access to confidential information, I agree to abide by the following:

1. I understand that the right of confidentiality applies to all patients and that all patient information is confidential (not just diagnosis and treatment). I understand that as an Observer, I am not permitted access to patient records. I understand that I am obligated to report privacy violations immediately to my shadowing sponsor.
2. I understand that my obligation under this agreement continues after the termination of my observing.
3. I understand that patients have a right to provide consent for me to observe their medical care and if a patient does not provide consent to my sponsor, I will not be allowed to be present during medical care.
4. I understand that all information is the property of GVH and shall not be used inappropriately or for personal gain and shall not be removed from the premises without prior authorization. I also understand that all electronic communication shall be monitored and subject to internal and external audit.
5. I understand that GVH considers intentional and unintentional breaches of patient information a very serious matter. Violations to security and privacy policies will result in appropriate disciplinary actions.
6. I understand that if I discuss confidential information in violation of this Agreement, I could be held personally liable for such violation and/or be required to indemnify Gunnison Valley Health for any damages, attorneys' fees, and costs in defending against any such claims.
7. I agree to abide by all rules and regulations as specified in GVH policies. I can request a copy of these policies be provided to me.
8. I understand that if l have any questions regarding this Agreement, I should contact my sponsor.
9. I understand that by signing this document I am agreeing to comply with the above terms.

 I have read the GVH Shadowing Agreement and I understand that violation of this agreement may result in disciplinary action by Gunnison Valley Health or its healthcare affiliated entities, in accordance with GVH policies, Colorado state laws, and federal laws.

PURPOSE: For security and public relations reasons, Gunnison Valley Health requires all employees to wear a picture identification badge identifying them as a "Observer/Shadow" of Gunnison Valley Health.

POLICY: All "Observer/Shadow" are required to wear a picture identification badge at all times, that includes their name, title and department. A replacement badge will be supplied to "Observer/Shadow" who changes their name, job or department.

ID badges are the property of Gunnison Valley Health and must be turned in to Human Resources upon job termination.

I agree to the above Policy: