It is the legal and ethical responsibility of all contractors to use personal and confidential patient, employee and client business information (referred to collectively as "confidential information") in accordance with the law and client facility policy, and to preserve and protect the privacy rights of the subject of the information as they perform their contracted duties.
Laws controlling the privacy of, access to, and maintenance of confidential information include, but are not limited to, the federal Health Insurance Portability and Accountability Act (HIPAA). These and other laws apply whether the information is held in electronic or any other form, and whether the information is used or disclosed orally or in writing.
Confidential information includes information that identifies or describes an individual and the disclosure of which would constitute an unwarranted invasion of personal privacy. Examples of confidential employee and business information include:
By my signature below, I authorize Alliance Medical Staffing, Inc. ("Alliance") to conduct background and reference checks on me regarding any information related to possible placement as a temporary assignment provider. This includes information on my education, licensing, work history, Medicare/Medicaid sanctions, malpractice claims and insurance eligibility, and criminal history. Alliance may gather information from various sources including, but not limited to, consumer reporting agencies, hospitals, medical institutions or organizations, personal references, physicians, employers (past and present), business and professional associates (past and present), governmental agencies and instrumentalities (local, state, federal or foreign), university transcript offices, medical schools, the Office of Inspector General and the Federation of State Medical Boards.
I authorize Alliance to confirm information contained on any document that I provide to Alliance, including my curriculum vitae. I consent to Alliance sharing this information with Alliance clients and affiliates. I understand that, upon my request, Alliance will disclose the nature and scope of information contained in my file in accordance with federal law. A request for disclosure of information contained in my file must be made in writing and directed to my Recruiting Consultant.
I authorize the above-named entities and individuals to release to state licensing boards, hospitals and Alliance any information (written or oral) including medical information, files or records about me in their possession required for evaluation of my qualifications for placement as a locum tenens provider. I hereby release the above-named individuals and entities, including Alliance, from all liability for the release of information to as state licensing board, hospital or its agents. I further authorize Alliance, its agents and affiliates to release this information, including medical information, to (i) federal, state, county or local government entities, (ii) hospitals or other health care facilities, (iii) insurance providers or (iv) any other person upon a showing that the release of information is vital to the general public's health, safety and welfare.
I make this release for the purpose of allowing Alliance to assist in my request for a license to practice in my specialty and to assist in my efforts to work as a temporary assignment provider for Alliance clients.
My signature below also signifies my consent to provide blood and/or urine samples for testing to determine the presence of drugs or alcohol in my body, as well as my consent to have the results of such results disclosed as described above, and my release of Alliance, its directors, officers, agents and employees from, and my agreement to hold them harmless from any and all liabilities, claims, losses, costs and expenses whatsoever (including attorney's fees and court costs) arising out of or resulting from any such testing or disclosure. I also consent to random drug screens which may be authorized by Alliance, its directors, officers and agents. Random drug screens may also be authorized by the healthcare organization, its directors, officers and agents, of which I am a locum tenens provider.
I realize that the results of this testing will be shared to the extent required or permitted by applicable law, which disclosure may include, but not limited to, me, officers, employees and agents of Alliance who need the information for reasons connected with their employment.
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Release, Hold Harmless and Indemnification
For myself and my successors, heirs and assigns, I hereby release Alliance Medical Staffing and its representatives and agree to hold them harmless from, and indemnify them and each of them against, any and all liability, claims, losses, costs and expenses, of any kind or nature (including attorney's fees and court costs) arising out of or resulting from my electing or declining the Hepatitis B vaccination.