Option 1 - I have had Chickenpox
Option 2 - To my knowledge, I have not had Chickenpox. I have been informed that a titer can be done to determine my immunity to varicella. I understand that this titer will be my financial responsibility. I also understand that should the titer indicate that I am not immune to varicella, it is recommended that I obtain the varicella immunization. The varicella immunization will also be my financial responsibility. I wish to obtain the titer and, if necessary, the vaccine. I will provide documentation of the varicella titre and/or the varicella vaccination to my school.
Option 3 - To my knowledge, I have not had Chickenpox. I have been informed that a titer can be done to determine my immunity to varicella. I understand that this titer will be my financial responsibility. I also understand that should the titer indicate that I am not immune to varicella, it is recommended that I obtain the varicella immunization. The varicella immunization will also be my financial responsibility. At this time, I choose not to obtain the titer to determine my immunity to varicella. I am aware that I may not be immune to varicella and that a.) I may contract varicella by exposure to chickenpox or shingles in the healthcare setting b.) If I am pregnant and contract varicella, this may result in serious health consequences for both myself and my child c.) Should I contract varicella, I may carry the illness to MSHA patients, MSHA employees, or persons in the community including my family and friends d.) If I am exposed to varicella virus, I am to notify MSHA Employee Health and my school immediately and I will be relieved from duty from day 10-21 post exposure.
HIV Post-Exposure Prophylaxis
Although preventing blood exposure is the primary means of preventing occupationally acquired human immunodeficiency virus (HIV), appropriate post-exposure management is an important element of healthcare workplace safety. Immediate treatment post-exposure may reduce the risk for HIV transmission. If you are exposed to blood or body fluids from a person known to be HIV positive, report this immediately to your instructor and/or MSHA preceptor. Treatment should be initiated promptly, preferably within 1-2 hours, at a MSHA emergency department. Treatment is provided at your expense.
Mountain States Health Alliance has a long tradition of protecting the privacy of patient information, including patient names, addresses, telephone numbers, social security numbers, diagnoses, pharmacologic and surgical interventions as well as the testing and results associated with the delivery of care to a patient at any MSHA facility. MSHA’s commitment to patient confidentiality is reinforced by the privacy and security regulations created as part of the Health Insurance Portability and Accountability Act (HIPAA).
In addition, MSHA has intellectual property that must be protected. Such information may be disclosed for purposes for particular business purposes. MSHA business related property must not be used, copied, distributed or disclosed without appropriate authorization or contractual agreement.
I understand that maintaining the confidentiality of patient and business information is a condition of my continued relationship with MSHA. Therefore, I agree to maintain the confidentiality of all patient information, as well as any business related information that may become known to me in the course of my relationship with MSHA. This includes patient and business information that may be incidentally disclosed to me as a result of my presence in a MSHA facility.
I understand that any breach in confidentiality, including but not limited to any inappropriate use or disclosure of patient information is a violation of MSHA policy, and such a breach will result in appropriate actions, up to and including termination of my relationship with MSHA. In addition, such a violation may be considered a violation of federal regulations and be subject to investigation by the Office of Civil Rights.
- It is an expectation and responsibility of anyone who provides services for or within any MSHA facility to insure the utmost privacy and security of patient and business related information. This includes all information whether written, spoken, observed, in a computer system, or any other form or media.
- Patient information will be managed in accordance with MSHA policies and all applicable state and federal requirements. Patient information will only be accessed, used or disclosed in a manner necessary to perform job duties based on a need to know. It is a patient’s right to expect that their information will be treated in a confidential and secure manner. The patient has the right to expect that their health information will be safeguarded and protected.
- Patient information will be used or disclosed only as needed to support the purpose of the intended use or disclosure consistent with professional judgment and reasonableness. It is an expectation of anyone disclosing patient information to insure they are authorized to do so, to know whether the recipient is authorized to receive the information and to insure the request is appropriate for the content and purpose within professional judgment and reasonableness.
- Patient information will be protected from any intentional or unintentional use or disclosure that is in violation of MSHA policy and/or state and federal regulations. Any breach in confidentiality of patient information is a violation of MSHA policy, and such a breach will result in appropriate actions, up to and including termination of relationship with MSHA. In addition, such a violation may be considered a violation of federal regulations and be subject to investigation by the Office of Civil Rights.
- MSHA business and intellectual information is considered property of MSHA. It may not be used directly or indirectly for personal gain, nor be used, copied, distributed or disclosed without appropriate authorization. Anyone possessing proprietary information must handle the information in a manner so as to protect it against improper access, use or disclosure.
- Copyrighted materials may not be duplicated without written permission of the license holder for use on MSHA premises or elsewhere.
- It is an expectation that all team members, students and those doing business with MSHA conduct their behavior in a manner consistent with basic workplace compliance and ethics standards.
printable pdf of this agreement