ACKNOWLEDGEMENT
I acknowledge that I have received, read and understand
the Community Health Systems ("CHS") Code of Conduct.
I agree to abide by the compliance policies !1-ummarized in the Code of Conduct
and all federal, state, and local laws, rules and regulations
for the duration of my association with CHS.
ft lex fa Jn°3elliet1
inted Name
Date
NorthWest Medical Center
Facility
CHS-CODE-ACK 09-16
0
o~CHS
Co1nmunity
Health Systems
22
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~
CHS Hrahh Sy<iem,
Communi1y
Work force Inform ation Secur ity Agree ment
I understan d that the facility or business entity (the " Company ") in which
or for whom I work, voluntee r or provide services, or with
whom the entity for which I work has a relations hip (contract ual or otherwise
) involving the exchange of health informati on, has a
legal and ethical responsib ility to safeguar d the privacy of all patients and
to protect the confiden tiality of their patients' health
infonnati on. Addition ally, the Compan y must assure the confiden tiality
of its human resources, payroll, fiscal, research, internal
reporting . strategic planning , commun ications, compute r systems and managem
ent informat ion (collectiv ely, with patient identifiab le
health infom1ation, "Confide ntial Infomrnt ion").
In the course of my employm ent / assignme nt at the Company , I understan
d that I may come into contact with this type of
Confiden tial Informat ion. 1 will access and use this infonnati on only when
it is necessary to perfom1 my job related duties in
accordan ce with the Compan y's Privacy and Security Policies, which are
available on the Company intranet. r further understa nd
that I must sign :111d comply with this Agreem ent in order to obtain
authoriz ation for access to Confiden tial Informat ion.
I. I will act in the best interest of the Compan y and in
9. I will not in any way copy, release, sell, loan, aher, or
accordan ce with its policies. procedur es and Code of
destroy any Confiden tial Informat ion except as properly
Conduct at all times during my relations hip with the
authorize d.
Company .
10. I will not make unauthor ized transmiss ions, inquiries .
2. I understa nd that I should have no expectat ion of privacy
modifica tions, or purgings of Confiden tial Informat ion.
when using Compan y informat ion systems. The Company
11 . I will practice secure electroni c commun ications by
may log, access, review, and otherwis e utilize infonnati on
transmitt ing Confiden tial Informat ion only to authorize d
stored on or passing through its systems, including e-mail, in
entities, in accordan ce with approved security standards .
order to manage systems and enforce security.
12 . I will only access electroni c systems to review patient
J. l understa nd that I have no right to any ownersh ip interest in
records for which my job responsib ilities have a legitimat e
any informat ion accessed or created by me during my
need to access for treatmen t, payment or healthcar e
relations hip with the Compan y.
operation s.
4 . I will practice good workstat ion security measures such as
I J. I will notify my manager or appropri ate Informat ion
locking up diskettes when not in use, using screen savers
Services person if my password has been seen, disclosed ,
with activated password s appropri ately, and position screens
or otherwis e comprom ised, and will report activity that
away from public view.
violates this agreemen t. privacy and security policies, or
5. I will only access or use systems or devices I am officially
any other incident that could have any adverse impact on
authorize d to access. and will not demonst rate the operation
Confiden tial Infom,at ion.
or function of systems or devices to unauthor ized
14. Upon terminati on, I will immedia tely return any
individua ls.
documen ts or media containin g Confiden tial lnfon11a1ion
6. I will :
to the Company .
a . use only my officially assigned user ID, password , etc.
15. I agree t11at my obligatio ns under this Agreeme nt will
b. use only approved licensed software .
continue after terminati on of my employm ent, expiratio n
c . use devices with virus protectio n software .
of my contract, or my relations hip ceases with the
d . report theft or loss of mobile devices (cell phones, PD As,
Compan y.
laptops, etc.) that store Confiden tial Informat ion within
16. I understa nd that violation of this Agreeme nt may result in
24 hrs.
disciplin ary action, up to and including terminati on of
7. I will never:
employm ent, suspensi on and loss of privilege s, and/or
a. share or disclose user lDs or password s, nor will I ask
terminati on of authoriza tion to work within the Company ,
others to do so.
in accordan ce with the Compan y's policies.
b. use tools or techniqu es to break or exploit security
measures .
The following statements apply to physicians and
c. connect to unauthor ized network s through the Compan y's
contracted entities using Company systems containing
systems or devices.
patient identifiable health information:
d. knowing ly include, or cause to be included , any false,
I. r will insure that only appropri ate personne l in my office
inaccura te or misleadi ng entry in any record or report.
will access the Compan y' s electroni c systems and I will
8. [ will not disclose or discuss any Confiden tial Infonnat ion
aru1ually train such personne l on issues related to patient
with others, including friends or family, who do not have a .
confiden tiality and access.
need to know it.
2. I will accept full responsib ility for t11e actions of my
employe es who may access the Compan y's electroni c
systems and Confiden tial Infom1at ion.
I acknowl edge that I have read this Agreem ent and I agree to comply
with the terms and conditio ns stated above.
e (;rnploye e, Consulta nt. Vendor, Oftice staff, Phys(cian )
,/
F~<:i~ty Name
NWMC
Dept.
NWACC
STUDENT INFO RMAT ION AND VERIFICATION CHECKLIST
Students Name:
Be.l/Ci\
Mailing Address:
\/isiQ AR 7J7I
Last 5 SSN#
Phone Numbe r:
Date of Birth:
00
30
Grad Date: May 2022
Relatio nship/P hone #
Emergency Contact:
Clinicals Start Date: Januar y 2021
Grad Date: May 2022
Name of School /Institu tion: NWACC
rnrc
mca Location:
Willow Creek
Benton ville
Department Affiliation: Clinicals
Position Title: Nursing Student
prrng a e
Documents required prior to student placement
1 Informa tion Sheet for Studen t
2 Confide ntiality Statem ent
to the EMR)
3 Workfo rce Informa tion Security Signed (if school requires student access
view access to verification
or
d
Criminal Background check within the last 12 months (Copy require
l record or activity is
site) (Federal, State, Local Nationa l Scan and Sex Offende r Check) If crimina
attend the facility)
4 discovered, HR will need to review prior to allowing the student to
(Copy required or view access to
Negative Results of a 10 Panel Drug Screen within the last 12 months
allowing the student to attend
verification site) Positive results will need to be reviewed by HR prior to
5 the facility.
Require per Contract an Mamt ame
made vailable
em,c Faci 1ty Documents s
Service Now request
---
Username Sent_ _
J
-J
e
6 Curren t CPR Card
Results or Series Started
7 Hepatitis B Docum entation of Vaccine Series Given/Positive Titer
within the last 12 months or
One (1) Negative TB Test Docum entatio n/ Negative IGRA Docum entation
8 Previous Positive Docum entation and Signs and Symptoms Form
J
J
CONFIDENTIALITY AGREEMENT
Al@s ili~£n5en
,
I,
recognize and acknowledg e that, in the performance of my services at Northwest Health
System (the '~ospital") as an independent contractor, as an employee of a staffing agency, or as a student, I will be
working with and have access to certain Confidential Information. Confidential Information includes, but is not limited
to, information disclosed to me or known by me as a result of my association with the Hospital and the services I
provide to the Hospital and information about the Hospital's operations and other matters (whether or not such
information constitutes a trade secret) that are of a confidential or proprietary nature, including and related to, but not
limited to, patient background information, medical records or other medical information, diagnostic reports, Hospital
organizational information, clinical information, computer data, and financial information in whatever form such
information may exist including any charts, records, manuals, data, computer data, notes, drawings, graphs, analyses,
and related materials.
I agree to keep all such Confidential Information in strict confidence and will not at any time, during or after the
performance of services for the Hospital, disclose or disseminate any Confidential Information that I may be provided or
have access to as a result of my association with the Hospital and the services provided to it to any third party except in
connection with and as necessary to the performance of my services for the Hospital and with any further patient
consent as may be required. Specifically, but without limiting the foregoing, I agree not to disclose any Confidential
Information to persons not authorized by the Hospital, and I further agree that Confidentia l Information must not be
disclosed to competitors, suppliers, contractors, family members, or other Northwest Health System employees. I also
agree not to reproduce, transmit, transcribe, or remove from the premises of the Hospital any Confidential Information
except in connection with and as necessary to the performance of my services for the Hospital. Furthermore, I agree not
to use any Confidential Information for my personal gain or for that of persons not affiliated with the Hospital.
I understand and agree that I am obligated to maintain patient confidentiality at all times whether or not such patient
confidentiality involves Confidential Information. I understand that it is not permissible to discuss patient-relat ed
Confidential Information in public places or with persons that have no reason to know the patient's medical care or
treatment.
I understand and agree that any and all computer system access codes and passwords that are assigned to me are
confidential. I will not disclose any such codes or passwords to anyone other than as necessary in connection with the
services I provide to the Hospital. If I have reason to believe that the confidentiality of such codes or passwords have
been violated, I will contact the MIS Department of the Hospital immediately. Upon termination of my independent
contractor relationship, I understand that any and all codes and passwords that have been assigned to me will be deleted
from the appropriate system(s) and that I will have no right or interest in any data related thereto. Notwithstan ding the
terms of this Confidential ity Agreement, I understand and agree that I have no personal expectation of privacy with
respect to any Confidential Information .
I understand that any deviation from the requirements set forth in this Confidential ity Agreement could result in legal
liability and legal action against the organization and myself. I further understand that any breach of this Confidentiality
Agreement, intentional or unintentiona l, may result in immediate termination of my contractual relationship with the
Hospital.
My signature below certifies that all of the above confidentiality requirement s have been explained to me, that I was
afforded the opportunity to ask questions about such requirements, and that I agree to be bound by the terms of this
Confidentiality Agreement.
I2/()(d[[Jf)
Date
\fonns\fonn I ?-Confidentiality Agmt Contractor.doc
HR FORM 17