EMS University

Allegiance Mobile Health Third Rider Packet

All riders must complete this packet and turn it in to an Allegiance Manager for approval. Ride-alongs are not permitted unless this packet is complete and approved by an Allegiance Manager.

Rider Information

EMERGENCY CONTACT

ORGANIZATION  INFORMATION

Application Approval (For Department Use Only)

Reviewed by: __________________________
Date: _________________________________

Pages 1-4 signed and completed in full?
☐ Yes ☐ No

Approved: ☐
Denied: ☐
Denial Reason: _________________________________________________

Applicant notified of denial or acceptance on (Date): _____________________

Allegiance Mobile Health
Allegiance Mobile Health Ride-Along Requirements

There are inherent risks involved in participating in a ride-along and all riders are required to fully read, understand, and agree to the instructions and waivers in this packet. With the appropriate safeguards, non-EMS personnel can ride safely and gain a good perspective on EMS operations and the types of services Allegiance Mobile Health provides.

Dress/Equipment

All riders are expected to look neat, professional and wear appropriate attire while on a ride-along. This includes dark navy blue or black pants (No Shorts or Jeans) and black shoes or boots (No Sneakers). A white, blue or black button down or polo (No T-shirts) is preferred and it must not contain advertising or emblems. For safety reasons hair must be pulled back, away from the face and earrings are limited to one small stud per ear. No hoop or clip-on earrings or any facial jewelry or visible body piercing will be allowed. Necklaces must be worn on the inside of shirts; no dangling jewelry is permitted. No heavy perfume or cologne.

Conduct/Safety

All riders are expected to strictly adhere to the safety and conduct requirements outlined below:

• You must follow ALL direction given to you by Allegiance personnel.

• At the direction of the crew, you must wear any personal protective equipment.

• You are not to discuss any patient information with the ambulance crew unless directed otherwise. If you are unable to complete your ride-along for any reason, you must notify the ambulance department contact person.

• You must remain seated and seat belted in any vehicle that is in motion.

• You may only ride in the ambulance when supervised by an Allegiance crew member.

• At no time may you perform any task that has a position on all items functioning in the ambulance unless under the direct supervision of an Allegiance crew member.

• You may not enter any scene unless directed by Allegiance Mobile Health.

• At no time are you permitted to operate any vehicle owned by Allegiance Mobile Health.

• You are expected to behave professionally and courteously to patients, bystanders, crew members, and other agencies involved with a call.

• You must immediately report any injury, illness, or other problem to a crew member.

A rider who violates any safety or conduct guidelines may have their ride-along terminated.

Please carefully read and agree to the following statement:

I, ______________________________________, have read the above Allegiance Mobile Health ride-along guidelines and I agree to abide by them. I understand that a violation of any of the above policies is grounds for termination of my ride-along. I also consent to the use of my photograph, name, and address by Allegiance Mobile Health to publicize and make reports about this ride-along program.

Rider’s Signature: _____________________________ Date: _______________

Riders under 18 require a parent/legal guardian signature.

Parent/Legal Guardian Name: ___________________ Date: _______________

Parent/Legal Guardian Signature: ________________________________________

Allegiance Mobile Health Confidentiality (HIPAA) Guidelines

Federal law prohibits the unauthorized sharing of patient information. Patient information such as their name, demographic data, medical condition, or any other identifying information is strictly confidential and is NOT to be disclosed, in any form, to anyone except ambulance personnel and others who are authorized under HIPAA to receive such information. Riders are encouraged to treat ALL patient information as confidential and to consult the ambulance crew with any questions regarding HIPAA laws.

Please carefully read and agree to the following statement:

I, _______________________________________, will treat all patient identifiable information as strictly confidential. This information includes, but is not limited to, the patient’s name, address, telephone number, date of birth, age, social security number, medical condition, treatment received, and past medical history. I will not share, in any form, patient identifiable information with friends, family, or community members not directly involved with patient care. If, at any time during or after the ride-along, I am asked a question about a patient, I will refer the asking person to the ambulance crew or an Allegiance Mobile Health leadership member. I understand that if I disclose patient identifiable information, even unintentionally, I may be subject to civil and/or criminal penalties.

Allegiance Mobile Health Waiver of Rights and Release of Liability

The Waiver of Rights and Release of Liability specifically pertain to any injuries to the undersigned while he/she is a passenger in any ambulance or other vehicle owned or operated by Allegiance Mobile Health, or injuries sustained in the course of responding to a call including while enroute, on scene, or at any facility arising from or associated with the ride-along.

The inherent dangers associated with a ride-along include, but are not limited to, accidents involving the ambulance, negligent or intentional tortious acts by third party persons, exposure to communicable diseases, and various accidents during the provision of emergency medical treatment. I also understand that I may witness traumatic injuries or events that may leave a lasting impression.

As used herein, the word “injuries” shall include bodily injuries, injuries to personal properties, mental anguish, emotional distress and/or death resulting from such bodily injuries. All reference herein to the undersigned shall include not only the individual signing this document, but also his or her personal representative, heirs, and survivors.

I shall indemnify and hold harmless Allegiance Mobile Health and its directors, officers, employees, agents, affiliates, subcontractors and customers from and against all allegations, claims, actions, suits, demands, damages, liabilities, obligations, losses, settlements, judgments, costs and expenses (including attorney’s fees) which arise out of, relate to, or result from any act or omission of Allegiance Mobile Health.

Allegiance Mobile Health will make every possible effort to conclude the ride-along at its scheduled termination time. However, because of the nature of emergency operations and unforeseen incidents beyond its control, Allegiance Mobile Health assumes no liability or responsibility for any expenses incurred due to late conclusion of a ride-along.

In addition to waiving rights and liability as specified above, the undersigned, by signing this document, represents that he/she has read, understood, and received a copy of this document; and that he/she is fully aware of the risks inherent in participating in the ride-along. The undersigned also acknowledges that if any single provision of this Waiver is declared unenforceable that such declaration has no effect on the enforceability of the remainder of the Waiver. This Waiver shall become effective upon its signing.