Student / Ride-Along Application

Given the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course of our work. Bellevue-Dayton Fire/EMS Department prohibits the release of any patient information to anyone outside the organization unless required for purposes of treatment, payment or health care operations and discussion of Protected Health Information within the organization should be limited. Acceptable uses of PHI within the organization include, but are not limited to, exchange of patient information needed for the treatment of the patient, billing and other essential health care operations, peer review, internal audits and quality assurance activities.

I understand that Bellevue-Dayton Fire/EMS Department provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy right of Bellevue-Dayton Fire/EMS Department patients. I understand that it is necessary, in the rendering of Bellevue-Dayton Fire/EMS Department services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected by federal and state laws.

I agree that I will comply with all confidentiality policies and procedures set in place by Bellevue-Dayton Fire/EMS Department during my employment or association with Bellevue-Dayton Fire/EMS Department. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify, in writing, the Privacy Officer of Bellevue-Dayton Fire/EMS Department immediately. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my employment or association with Bellevue-Dayton Fire/EMS Department. Upon termination of my employment or association for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession.

I have read and understand all privacy policies and procedures that have been provided to me by Bellevue-Dayton Fire/EMS Department. I agree to abide by all policies or be subject to disciplinary action, which may include verbal or written warning, suspension, or termination of employment or association with Bellevue-Dayton Fire/EMS Department. This is not a contract of employment and does not alter the nature of the existing relationship between Bellevue-Dayton Fire/EMS Department and me.

WHEREAS, the undersigned is desirous of and has requested from the Bellevue-Dayton Fire District, permission to act as an observer with the city Fire/EMS personnel, including the riding in a city-owned emergency apparatus, and accompanying Fire/EMS personnel as an observer in the performance of their Fire/EMS duties; and,

WHEREAS, it is understood that the Bellevue-Dayton Fire District cannot accept responsibility for or guarantee the safety of such individual or individuals when acting in such capacity as observers or riders;

Now, Therefore, BE IT AGREED as follows:

That in consideration of his or her being permitted as an observer to ride in a city-owned emergency response apparatus with the city Fire/EMS personnel and to accompany the Fire/EMS personnel in the performance of their duties, the undersigned hereby, in signing below, releases and forever discharges the Bellevue-Dayton Fire District, its employees and agents, including but not limited to Fire/EMS personnel of the Bellevue-Dayton Fire District, from every such claim, demand, damage, liability, action or cause of action of any kind or nature, for or on account of any personal injury or damage or injury or damage to property of any kind or nature sustained, whether caused by the negligence of the Bellevue-Dayton Fire District, its agents or employees, including but not limited to Fire/EMS personnel, or otherwise.

The undersigned hereby further agrees to hold the Bellevue-Dayton Fire District, its agents and employees, including but limited to Fire/EMS personnel completely harmless from any claim, demand, damage, liability, action or cause of action of any kind which may arise against any or all of them resulting in any way from his or her riding with a City of Bellevue-Dayton Fire/EMS personnel in a city-owned emergency response apparatus while accompanying any Fire/EMS personnel in the performance of their duties and acting as an observer thereof.

The undersigned has reviewed SOP #412.01, EMS Student/Observer Program and will comply with the requirement of the standard.