1. Given the nature of our work, it is imperative that we maintain the confidentiality of patient information that we receive in the course of our work. Mecklenburg EMS Agency prohibits the release of any patient information to anyone outside the organization unless required for purpose of treatment, payment, or healthcare operations and discussions of Protected Health Information (PHI)within the organization.
2. Acceptable uses of PHI within the organization include, but are not limited to, exchange of patient information needed for treatment of the patient, billing, and other essentials healthcare operations, peer review, internal audits, and quality assurance activities.
3. I understand that Mecklenburg EMS Agency provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy rights of patients. I understand that it is necessary in the rendering of services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written, or photographic and all such information is strictly confidential and protected by federal and state laws.
4. I agree that I will comply with all confidentiality policies and procedures set in place by Mecklenburg EMS Agency during my entire association with Medic. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify Medic immediately by sending an email to MadisonK@medic911.com. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my association with Mecklenburg EMS Agency.
5. I understand that I may never take pictures or patients or scenes, write down patient information, or in any way use or release patient information during or after my ride time with Medic. This includes patient names, date of birth, dates of transport, pickup or drop off locations, medical status or any other information associated with any patient I encounter during my association with Medic.

I, the undersigned, hereby request to accompany the Mecklenburg EMS Agency personnel on emergency and routine medical calls for the purpose of expanding my personal and professional interests and abilities. I am fully aware of the potential risks and dangers involved, the possibility of witnessing emotionally traumatic situations and that unexpected dangers may arise during such activities. I assume all risks of injury to my person, both mental and physical, or property that may be sustained in connection with the stated and associated activities.

In consideration that permission is granted to me to ride on a Mecklenburg EMS Agency ambulance, I do hereby, for myself, my heirs, administrators and assigns release, remise and discharge the Mecklenburg EMS Agency from all claims, demands, action and causes of action of any sort, for injuries sustained by my person, both mental and physical and/or property during my presence on said premises and participation of the stated activities.

I represent myself and certify that my true age is stated below. I certify that my attendance and participation in the above stated activities is voluntary and that I am of sound body and mind.

I certify that I fully read the waiver and release, confidentiality forms and guidelines. I certify that I fully understand all that has been written as it applies to me.

Lastly, I understand that any rider - at any time or reason shall be subject to removal and/or rejection from this program without explanation.