EMS University

Student/Guest/Trainee Confidentiality and Non-Disclosure Agreement
ProTransport-1, LLC/Student Trainee Confidentiality and Non-Disclosure Agreement

I, ____________________________, understand that ProTransport-1, LLC (“ProTransport-1”) provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy rights of ProTransport-1’s patients. I understand that it is necessary, in the rendering of ProTransport-1’s services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographed and that all such information is strictly confidential and protected from improper use and disclosure by federal and state laws.

I agree that I will comply with all confidentiality and security policies and procedures set in place by ProTransport-1 during my experience as a student/guest/trainee with ProTransport-1. If at any time I knowingly or inadvertently breach the patient confidentiality or security policies and procedures, I agree to notify the Privacy Officer of ProTransport-1 immediately.

I also understand that I may be exposed to other confidential or proprietary information of ProTransport-1 and I agree not to reveal any of that information to anyone at any time.

In addition, I understand that a breach of patient confidentiality may result in immediate suspension or termination of the privilege to gain clinical experience or observe the activities of ProTransport-1. Upon termination of this privilege for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. As a rule, I understand that any patient or confidential information that I see or hear while a student/guest/trainee will stay here at ProTransport-1 when I leave.

I understand and agree that I may have exposure to injury and illness (including COVID-19) as I participate in clinical activities. I understand that I am responsible for my own protective measures such as PPE in accordance with CDC guidelines and must adhere to the Company’s PPE policy and procedures.

I understand that this ride along is solely intended to afford the EMT program you are attending an avenue for you to complete the required number of ride time hours and/or the required number of patient contacts. In accordance with the Anti-Kickback Statute (42 USC § 1320a-7b(b)) Pro Transport-1 has no interest in offering, soliciting, or receiving anything of value nor will we use this program in any way to obtain or later leverage for the purposes of inducing payments by Medicare, Medicaid, or any Federal Healthcare Programs.

I agree to abide by all ProTransport-1 policies or my privilege to participate in clinical activities or to otherwise observe ProTransport-1 activities will be terminated.

Signature: ________________________________
Date: __________________

Name: ____________________________________

WAIVER, RELEASE OF LIABILITY & CONFIDENTIALITY PROTRANSPORT-1, LLC

I, the undersigned, know that participating as an observer with ProTransport-1 may be potentially hazardous and I understand that my participation is of my own free will and choice. In choosing to observe with ProTransport-1, I fully accept and assume all risks, whether before, during or after the ride-along. These include, without limitation, physical injury, psychological injury, exposure to diseases, emotional distress, trauma, actions, illness, death, contact with other participants or patients, equipment failure, inadequate safety equipment, the effects of weather, including extreme temperature or conditions, traffic, surface conditions, the vehicle and its operations, collision with the vehicle or fixed objects, and the actions of others including staff and patients. All risks are known and appreciated by me. I waive any and all specific notice of the existence of the risks. I shall assume and pay any and all medical and emergency expenses in the event of injury, illness, exposure or other incapacity regardless of whether I authorized such expenses. I further understand that I am not considered an agent of, or employee of ProTransport-1.

Knowing these facts and in consideration of being allowed to observe and/or engage in my behalf, releases, waives, discharges, covenant not to sue and hold ProTransport-1 and its affiliated entities, officers, directors, emergency and support personnel, volunteers and their representatives, agents and assigns, harmless from and against any and all claims and all other causes from recovery on account of any claims, demands and actions, of any kind on account of property damage, personal injury, or accidental death caused by, or related to, directly and/or indirectly, my participation in any ProTransport-1 event or my being on or property. I hereby release, waive any causes of action, for and absolve ProTransport-1 for bodily injury, personal injury, illness, emotional distress, death or property damage whether due to negligence, gross negligence, or failure to act, by the above-identified persons and entities or otherwise. This waiver and release is intended to discharge in advance ProTransport-1 and its affiliated persons and entities from and against any and all liability arising out of or connected in any way with my participation in any observation with ProTransport-1 even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above. I further agree to indemnify and hold ProTransport-1 harmless from any and all losses, damages, costs or expenses, including attorney’s fees, arising from or relating in any manner to my participation as an observer or from any breach of this Waiver and Release. I agree that I will be personally liable for any injury or damage I cause and that ProTransport-1 is not responsible for such injury or damage. I also understand that this agreement is binding on my heirs and assigns and is to be construed under the laws of the State of California.

Policy on Confidentiality and Protection of Patient Information

Given the nature of our work, it is likely that you will come into the possession of patient information that we receive in the course of our work. Therefore, we require strict confidentiality of all ProTransport-1 employees, volunteers and representatives unless required for purposes of treatment, payment, and operations. All contact and communication with the organization should be limited. Acceptable uses of PHI (Protected Health Information) include the information needed for the treatment of the patient, billing, and other necessary administrative purposes only.

All ProTransport-1 patient health information is private and confidential and that I am a crucial step in respecting the privacy rights of ProTransport-1’s patients. That patient health information may exist in various forms such as electronic, oral, written or photographed and all such information is strictly confidential and protected from improper use and disclosure by federal and state laws.

I agree that I will comply with all confidentiality and security policies and procedures set in place by ProTransport-1 during my entire association with ProTransport-1. If, at any time, I knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify the Privacy Officer of ProTransport-1 immediately. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my association with ProTransport-1 and that ProTransport-1 may take civil and/or criminal legal actions against me for such breach. Upon termination of my association for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession.

This is not a contract of employment and does not alter the nature of the existing relationship between ProTransport-1 and me.

By my signature I attest that I am of legal age to lawfully enter into this agreement or if a minor I have executed this agreement by the signature of my parent or guardian below. I have read this waiver, release, and confidentiality statement and agree to and accept all of its terms.

Signature of Rider/Observer: ___________________________
Address: ___________________________________________
Parent/Guardian if Participant is under 18: ___________________________
Typed or Printed Name: ___________________________
City: ___________________________
Date Signed: ___________________________