*Required 1Application2Confidentiality Statement General InformationName:* First Last Address:* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email:* PhoneI Would Like to Volunteer...(Check all that apply)Time(s): Morning Afternoon Day(s): Monday Tuesday Wednesday Thursday Friday Areas where I would like to help: Administration ARNP/PA Board of Directors Committees Dental Associate Fundraising Activities Medical/Dental/Providers Medical Records Associate Patient Care Pharmacist Vaccine Site How do you want to contribute? Administration Brochure Design & Distribution Clerical SKills Community Outreach Event Planning Health Education Health Fairs Marketing Patient Engagement Activites Patient Flow PLEASE NOTE: 1. PCHS will require your signature and agreement to protect patient/client confidentiality at the time of orientation. 2. PCHS is a drug-free, smoke free, alcohol free workplace. PENINSULA COMMUNITY HEALTH SERVICES NON-EMPLOYEE CONFIDENTIALITY STATEMENTAll patient Protected Health Information (PHI) - which includes patient medical and financial information – as well as employee records, financial and operating data of Peninsula Community Health Services, and any other information of a private or sensitive nature is considered confidential. Confidential information shall not be used or disclosed unless specific permission to do so has been obtained and granted by the privacy officer or designee. Applicable federal and state laws shall be followed to seek patient permission for any use or disclosure of PHI. Examples of inappropriate disclosures include: Discussing or revealing confidential information to friends or family members. Discussing or revealing confidential information to other coworkers or employees without a legitimate need to know. The disclosure of a patient’s presence in the office, hospital, or other medical facility, without the patient’s consent, to an unauthorized party without a legitimate need to know and that may indicate the nature of the illness and jeopardize confidentiality. Using patient information for marketing purposes without express permission from the Peninsula Community Health Services and patient. The unauthorized disclosure of confidential information can subject an individual and the individual’s employer to liability. Disclosure of confidential information to unauthorized persons, or unauthorized access to, or misuse, theft, destruction, alteration, or sabotage of such information, may result in your immediate removal from the premises and/or revocation of current and future visiting/working privileges of the individual and/or company, and may lead to legal action and/or a duty for you to mitigate damages. Confidentiality Agreement I hereby acknowledge, by my signature below, that I understand that patient PHI and other confidential or proprietary information of Peninsula Community Health Services which I may see or hear or otherwise gain knowledge of in the course of my visit/work with Peninsula Community Health Services is to be kept confidential, and this confidentiality is a condition of my privilege to visit/work with Peninsula Community Health Services. This information shall not be used or disclosed to anyone unless specifically authorized by Peninsula Community Health Services. The unauthorized use or disclosure of patient PHI is possible grounds for immediate removal from the premises; revocation of all future visiting/working privileges; legal action; and/or a duty to mitigate damages. Nothing in this agreement is intended to interfere with or discourage a good faith disclosure to any governmental entity related to a suspected violation of the law. An individual cannot and will not be held criminally or civilly liable under any federal or state trade secret law for disclosing otherwise protected trade secrets and/or confidential or proprietary information as long as the disclosure is made in 1) confidence to a federal, state, or local government official, directly or indirectly, or to an attorney and solely for the purpose of reporting or investigating a suspected violation of the law; or 2) a complaint or other document filed in a lawsuit or other proceeding, as long as such filing is made under seal. Peninsula Community Health Services will not retaliate against an individual in any way for a disclosure made in accordance with the law. In the event a disclosure is made, and the individual files a lawsuit against Peninsula Community Health Services alleging that the company retaliated against the individual because of this disclosure, the individual may disclose the relevant trade secret or confidential information to the individual’s attorney and may use the same in the court proceeding only if 1) the individual ensures that any court filing that includes the trade secret or confidential information at issue is made under seal; and 2) the individual does not otherwise disclose the trade secret or confidential information except as required by court order.Electronic Signature:* Date Signed:* MM slash DD slash YYYY Position:* UntitledFirst ChoiceSecond ChoiceThird Choice