AGRMT RE DIETETIC INTERN WITH RENAL CARE GROUP AZ LLC.PDF

DIETETIC INTERN AGREEMENT
This Dietetic Intern Agreement ("Agreement") is made by and between Maricopa County,
by and for its Department of Public Health (hereinafter referred to as "PROGRAM"), whose
principal office is located at 4041 N. Central Ave., Ste. 1400, Phoenix, AZ 85012, and Renal Care
Group Arizona, LLC (hereinafter referred to as "FMC"), whose principal office is located at 920
Winter St. Waltham, MA 02451.
IT IS AGREED by PROGRAM and FMC as follows:
WHEREAS, PROGRAM, a dietetic internship currently granted approval status by The
Academy of Nutrition and Dietetics, Accreditation Council for Education in Nutrition and
Dietetics (ACEND), a specialized accrediting body recognized by the Council on Postsecondary
Accreditation and the United States Department of Education (the "Education Program"); and
WHEREAS, as part of the Education Program, PROGRAM seeks to provide qualified
interns in the Education Program (each a "Dietetic Intern" and collectively, "Dietetic Interns")
with opportunities for observation and training in a clinical setting; and
WHEREAS, FMC owns and operates outpatient hemodialysis facilities at the locations set
forth on Exhibit A (each a "Facility" and collectively, the "Facilities"); and
WHEREAS, the Facilities are willing to provide a voluntary clinical education opportunity
(the "Clinical Placement") for the Dietetic Interns so long as such placement does not interfere
with the Facilities' obligations to their patients and does not reduce working hours for or displace
any FMC employees; and
WHEREAS, FMC has no financial ownership of or in PROGRAM; and
WHEREAS, the parties desire to establish their respective rights, responsibilities, and
obligations related to the Clinical Placement of Dietetic Interns at a Facility;
NOW THEREFORE, IT IS AGREED by PROGRAM and FMC as follows:
1 PROGRAM reserves to itself and will perform the functions of an accredited dietetic
internship and the administrative and educational program functions normally associated
with such_aninstitution,_generally7In-cid-errt-to-this7kgrenrrrentTP-ROGIttM-straThagree-to
or perform the following:
a. Assure that Dietetic Interns have been oriented to expected outcomes of the Clinical
Placement
b. Provide classroom theory and practical instruction to Dietetic Interns and ensure
that all Dietetic Interns have successfully completed appropriate education and
training prior to their Clinical Placements at a Facility. A list of programs, courses
and training that Dietetic Interns need to complete in order to have such appropriate
education and training is described on Exhibit B.
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c. Cooperate with FMC to assure that Dietetic Interns understand and abide by the
administrative and clinical policies, procedures, standards and practices of FMC.
d. Have final responsibility for the content and general implementation of all
educational programs at PROGRAM.
e. Furnish FMC with evidence, records, and/or documentation regarding each
Dietetic Intern's completion of appropriate health examinations, training,
certifications, and education as described on Exhibit D, subject, however, to
compliance with all applicable statutes, rules, laws and regulations respecting the
maintenance and release of records and or information derived from such records.
Such evidence, records, and/or documentation as described on Exhibit D shall be
furnished by PROGRAM to FMC prior to a Dietetic Intern's participation in a
Clinical Placement at a Facility. PROGRAM shall retain the necessary
documentation to verify canapliwace with this provision and will present evidence
to FMC upon request.
f. Arrange for meetings of PROGRAM and FMC staff as may be requested.
g. Maintain in full force and effect, during the existence of this Agreement,
comprehensive general liability insurance and specified medical professional
liability insurance coverage, or a comparable program of self-insurance, for all
Dietetic Interns in a Clinical Placement at a Facility, including coverage for any
acts of negligence of its Dietetic Interns, faculty, officers, or employees with respect
to any liability arising out of their participation in the Education Program or a
Clinical Placement in amounts not less than $1,000,000.00 per occurrence and
$3,000,000.00 aggregate per year. Upon request, PROGRAM shall submit proof
of such insurance to FMC.
h. Defend, indemnify and hold FMC and its past, present and future subsidiaries,
divisions, departments, successor, assigns, officers, directors, agents, medical
directors, employees, insurers, representatives and stockholders, harmless from and
against any and all liability, claims, actions, causes of action, lawsuits or damages
(collectively, "Losses") caused or arising out of the act(s) and/or omission(s) of
PROGRAM, its agents, its employees and Dietetic Interns incident to its/their
participation in the Education Program and/or Clinical Placement.
Defend, indemnify and hold FMC and its past, present and future subsidiaries,
divisions, departments, successors, assigns, officers, directors, agents, medical
directors, employees, representatives and stockholders, harmless from and against
any and all Losses caused or arising directly or indirectly from the classification of
Dietetic Interns treatment under this Agreement as neither employees nor
independent contractors of FMC, including without limitation any Losses related
to the failure of FMC or PROGRAM to provide and/or pay: compensation to the
Dietetic Interns, federal, state, or local taxes, Social Security, or similar taxes,
vacation pay, sick leave, unemployment insurance, worker's compensation,
retirement benefits, disability benefits, or employee benefits of any kind.
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a. "Defend" as used herein shall mean to provide a legal defense with attorneys of
FMC's choosing, including but not limited to attorneys' and witness, including
expert witnesses, fees and costs, for the defense of any actual or alleged Losses,
including but not limited to, associated with defending against any
governmental investigation.
Each participating Dietetic Intern shall carry mandatory health insurance coverage
under the PROGRA1VI's health insurance program or show proof of enrollment in
a comparable accident and sickness health insurance plan. No Dietetic Intern shall
be eligible to participate in any group health insurance plan sponsored by FMC.
2. FMC shall agree to or perform the following:
a. Provide a Clinical Placement to each qualified Dietetic Intern, at a Facility as
mutn2lly agreed upon by FMC, PROGRAM, and the Dietetic Intern, Approval
by the Medical Director and the Governing Body of the Facility must be obtained
prior to a Dietetic Intern being assigned a Clinical Placement at the Facility.
PROGRAM and FMC will mutually agree upon the days and hours that the
Dietetic Intern will participate in the Clinical Placement at the Facility.
b. Advise PROGRAM and/or Dietetic Interns of any incidental fees required for
Dietetic Interns.
c. Advise PROGRAM in writing of anticipated material changes in institutional
policies and procedures that affect the Clinical Placement sufficiently in advance
so that any appropriate changes may be made.
d. Allow PROGRAM faculty to visit and monitor Dietetic Interns participating in a
Clinical Placement at the Facilities.
c. Make a FMC staff member available as a resource person in accordance with the
plan schedule approved by both PROGRAM and FMC.
f. Allow Dietetic Interns, at FMC's discretion to perform only those tasks
commensurate with their level of education and experience and/or appropriate to
provide for the safety and welfare of patients, Dietetic Interns and the employees
- of the Fa-ci-lity
g. If requested by PROGRAM, complete Evaluation Reports of each Dietetic Intern's
performance which shall be supplied by PROGRAM. The requirements of such
Evaluation Reports may be dictated by an accreditation organization applicable to
PROGRAM.
h. Provide its own method of identification for each Dietetic Intern participating in a
Clinical Placement. PROGRAM will ensure that each Dietetic Intern conforms to
FMC's policies and procedures on safety, dress, conduct and health.
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i. Supervise activities of the Dietetic Intern while on the premises of the Facility and
orient Interns to appropriate rules, policies, regulations and procedures of the
Facility.
Obtnin written patient consent prior to allowing a Dietetic Intern access to a
patient's medical record using the form attached hereto as Exhibit C, and obtain
informed patient consent prior to allowing a Dietetic Intern to participate in patient
care.
Maintain in full force and effect, during the existence of this Agreement,
comprehensive general liability insurance, including personal injury, liability, and
property damage liability coverage (including contractual liability insurance for the
indemnification provisions of this Agreement), or a comparable program of self
insurance, in an amount not less than $1,000,000.00 combined single limit.
1. Make placements of Dietetic Interns at a Facility without regard to discrimination
on the basis of race, sex, age, national origin, disability, genetics, pregnancy, or
other protected categories under applicable laws. To the extent applicable to this
Agreement, both parties hereto agree to comply with all state and Federal laws,
rules, regulations, and executive orders as to equal employment opportunity, non-
discrimination and affirmative action including Arizona Executive Order No. 2009-
09.
m. Notwithstanding anything to the contrary in this Agreement, it is understood that
scheduling changes (including clinical assignments at a Facility) may be necessary
during the course of an academic term. FMC agrees to work with PROGRAM in
making any scheduling changes that may become necessary.
n. To allow Dietetic Interns enrolled in the Clinical Placement and in good standing
permission to complete their current clinical rotation so long as such Dietetic
Interns abide by FMC's policies and procedures.
o. No remuneration is to be made to FMC for its participation in the Education
Program or for the use of its Facilities for Clinical Placements.
p. Provide survey faints to Dietetic Interns during the course of their Clinical
Placement in order for_the_Dietdi_c_Inteuis_ tovaluate their experience in the
Clinical Placement.
3. PROGRAM and FMC further agree:
a. Dietetic Interns shall not be deemed to be employees or contractors of FMC or the
Facilities for purposes of compensation, fringe benefits, workers compensation,
unemployment compensation, minimum wage laws, income tax withholding, social
security or any other purpose because of their participation in the Education
Program or Clinical Placement, nor shall they be entitled to any of the rights or
responsibilities afforded to employees under local, state or federal law. Dietetic
Interns shall not be eligible for any fringe benefits, workers compensation or
unemployment compensation provided by FMC or the Facilities. Each Dietetic
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Intern is placed with a Facility to receive clinical experience and/or credit as a part
of his or her academic cun-iculurn, as well as in fulfillment of academic
requirements under supervision; those duties performed by a Dietetic Intern are not
performed as an employee, but in fulfillment of these academic requirements under
supervision. At no time shall a Dietetic Intern replace or substitute for any
employee of FMC. No Dietetic Intern shall have any expectation of employment
by FMC during or after the completion of the Education Program and PROGRAM
shall not suggest or imply to the contrary to the Dietetic Intern. This provision shall
not be deemed to prohibit the employment of any such Dietetic Intern by FMC
under a separate employment agreement upon completion of the Education
Program.
b. Dietetic Interns participating in a Clinical Placement under this Agreement shall be
limited to those individuals who are enrolled in the Education Program. A
description of the types of activities permitted to be undertaken by Dietetic Interns
is set forth on Exhibit E, attached hereto and incorporated herein by reference.
Dietetic Interns will be supervised at all times by a Registered Dietitian Instructor
("RDI"), an individual who is described in Section 3-c.
c. A RDI is an individnal who oversees the practical experience and training provided
to the Dietetic Intern for a particular rotation or rotations, maintains appropriate
contact with the Clinical Placement's program director and the Dietetic Intern to
coordinate planned learning experiences and assignments, and conducts the
Dietetic Intern evaluation. The RDI must meet the requirements set forth by the
Center for Medicaid and Medicare Conditions for Coverage for End-Stage Renal
Disease Facilities for dietitians and be an employee of FMC. The RDI must be
registered with the Commission on Dietetic Registration and have a minimum of
one (1) year professional work experience in clinical nutrition as a registered
dietitian, and if applicable, be licensed in the state in which he/she practices.
d. All Dietetic Interns participating in a Clinical Placement under this Agreement shall
attend orientation sessions and complete training in accordance with FMC's
policies and procedures. An individual Dietetic Intern's failure to complete such
compliance training, required orientation, or other orientation/training sessions
deemed necessary by FMC within a time prescribed by FMC may result in that
Dietetic Intern's removal from a Clinical Placement.
e. Pre-Engagement Screening: All Dietetic Interns participating in a Clinical
Placement under this Agreement will be required to undergo all standard pre-
engagement screening in accordance with the Pre-Screening Requirements (as
defined in the next subsection), including, without limitation, drug screening,
background checks and/or certain governmental checks, as a condition of their
placement for clinical observation and trainings hereunder. FMC's general
requirements for pre-engagement screening, which may be modified or
supplemented with respect to certain categories of Dietetic Interns from time to
time, are set forth in the applicable policies regarding Interns or interns. Pre-
Engagement Screening will be performed by FMC, at its cost and expense (unless
otherwise provided in any applicable statement regarding Interns). No Dietetic
Intern may begin performing clinical observation and trainings until such Dietetic
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Intern has successfully completed all required checks. Dietetic Interns will also be
required to sign individual statements regarding confidentiality, non-solicitation
and other matters, in accordance with FMC's standard policies for Interns.
f. Pre-Screening Requirements (as referenced by the previous subsection):
(i). Multi-County Background Check Requirements:
• OIG/GSA Exclusion - now FACIS - includes alias search (Level 3)
• Credential Verification if applicable
• Education Verification if applicable
• Background checks (last seven (7) years)
• Global Sanction (FBI List)
• County Felony Including Misdemeanor
• National Criminal File
• Social Security Verification
• National Sex Offender Registry
• Any other state-specific background checks or verifications required by
applicable state law
(ii). Ten (10) Drug Panel Test:
• Cocaine
• Opiates
• Amphetamines
• Barbiturates
• Methaqualone
• Methadone
• Benzodiazepines
• Phencyclidine
• Propoxyphene
• Marijuana
g. All records, files and other documentation concerning patients or business
operations of FMC shall be kept confidential and remain the sole property of FMC.
Each Dietetic Intern shall be required to execute a non-disclosure form, attached as
Exhibit F, prior to the commencement of a Clinical Placement at a Facility, as a
condition of participation under this Agreement.
h. Tthe-number-o-f-Dietetic-Intents-to-be-placed-ateach-Facifity-and-the-scheeltrling
of the instructional and/or clinical experience (as applicable) while at a Facility.
i. To assure that Dietetic Interns complete the number of hours and/or tasks of clinical
affiliation as outlined for a specific assignment and require that any absences,
including those due to illness, be made up.
Dietetic Interns must identify themselves as Interns in interactions with patients,
family members, and FMC staff.
k. Dietetic Interns may enter information into a patient's medical record so long as
such documentation is reviewed and co-signed by the RDI first.
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1. FMC may refuse to accept into the Clinical Placement any Dietetic Intern or faculty
who was previously discharged from employment with FMC or its affiliates or
would not otherwise be acceptable to FMC provided, however, that it shall notify
PROGRAM in writing of its refusal to accept the Intern or faculty and the specific
basis therefore.
m. PROGRAM shall instruct its Dietetic Interns on the importance of and their
responsibility for respecting the confidential and privileged nature of all
information which may come to their attention about patients and records of FMC
and the Facilities. The instruction shall include content related to the Health
Insurance Portability and Accountability Act, Public Law 104-191 ("HIPAA").
PROGRAM shall direct its Dietetic Interns to comply with FMC's policies and
procedures governing the use and disclosure of individually identifiable health
information under HIPAA. Solely for the purpose of defining the Dietetic Interns'
role in relation to the use and disclosure of FMC' s protected health information,
the Dietetic Interns are considered members of FMC s workforce, as that term is
defined under HIPAA, when engaged in activities pursuant to this Agreement. In
addition, PROGRAM agrees that a Dietetic Intern's breach of FMC's policies
concerning confidentiality shall be grounds for Dietetic Intern discipline by the
PROGRAM, including removal from the Facilities.
n. Each party agrees to comply with and to be separately responsible for compliance
with all laws, including but not limited to, anti-discrimination laws, which may be
applicable to their respective activities under this program. Dietetic Interns shall
observe all state and federal laws and regulations in their relationship with FMC
and PROGRAM.
a. That each party shall notify the other of any incident or claim it may reasonably be
anticipated to develop into a legal action as soon as possible, if such incident or
claim pertains to this Agreement. Notice will be provided forthwith in the event
that such a claim, lawsuit or other legal or administrative proceeding is commenced
incident to which indemnification may be sought from the other party as set forth
in this Agreement.
P. Both FMC and the PROGRAM reserve the right to affiliate with other institutions
and to place and/or accept, as the case may be, Interns from other college or learning
institution programs FMC shall_retain the_right_to_demandat antime,_the_
removal of a Dietetic Intern from the Clinical Placement portion of the Education
Program for any violation of FMC' s policies and/or procedures and/or regulations,
lack of qualification, health or other legitimate, lawful reasons. To the extent
practicable, such action will be preceded by consultation between the appropriate
personnel at PROGRAM and FMC. PROGRAM reserves the right, at any time,
to remove a Dietetic Intern from the Education Program for any violation of
PROGRAM' s policy and/or procedure and/or Intern regulations, unsatisfactory
academic performance, lack of qunlifications, health, or other legitimate and lawful
reasons.
q. Notwithstanding anything else contained in this Agreement, PROGRAM agrees
that FMC shall have the ultimate authority to approve any and all aspects of its
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involvement in the Clinical Placement as described in this Agreement.
Furthermore, PROGRAM agrees that FMC has the ultimate authority over the
Facilities and their grounds.
r. Neither party shall be an agent, joint venturer or partner with the other or use the
other's name or logo in any descriptive or promotional literature or communication
of any kind without the other's prior written approval.
4. Term and Termination.
a. The term of this Agreement shall be from February 1, 2018 through June 30, 2022.
The Agreement may be renewed for additional terms by the mutual consent of both
parties.
b. This Agreement may be terminated by either party upon thirty (30) days prior
written notice to the other party. Notwithstanding anything herein to the contrary
this Agreement shall continue until all of those interns participating in the dietetic
internship program at the time of written notice of the termination of the Agreement
have completed their training experience.
5. General Provisions.
a. This Agreement shall be reviewed by PROGRAM and FMC upon request of either
party but shall be subject to change only by the mutual consent of the parties; any
such change(s) shall become part of this Agreement only after being placed in
writing and signed by both parties.
b. The parties do not intend, and this Agreement shall not be construed to create any
direct or indirect rights and/or benefits to any third party whatsoever.
c. One or more waivers of any term or condition of this Agreement by either party
shall not be construed as a waiver of a subsequent breach of any term or condition.
No breach of a term or condition of this Agreement by either party shall be waived
by the other unless such waiver is in writing.
d. This instrument, together with all addendums and exhibits hereto, constitutes the
entire_Agreement_between_the_parties_ancLalLprior_discussions,agre_ements_and_
understandings, oral or in writing, are hereby merged into this Agreement. If any
term, provision, covenant or condition of this Agreement is held by a court of
competent jurisdiction to be invalid, void or otherwise unenforceable, the
remainder of the provisions of this Agreement will remain in full force and effect.
e. In the event there is a change in federal, state or local law, whether by statute,
regulation, agency interpretation or judicial decision that, in the reasonable opinion
of the counsel of either party, renders any of the material terms of this agreement
unlawful or unenforceable, then the applicable terms of this agreement shall be
subject to renegotiation upon written notice to the other party in order to remedy
such condition and conform the Agreement to the requirements of the law.
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f. Neither party shall assign this Agreement in whole or in part without the written
consent of the other, which shall not be unreasonably withheld, conditioned, or
delayed; provided, however, that FMC may assign this Agreement without the
consent of PROGRAM to an entity that acquires all or substantially all of the stock
or assets of FMC or to a successor by operation of law. Subject to this paragraph,
this Agreement will be binding upon and inure to the benefit of the parties and their
respective heirs, representatives, successors and permitted assigns.
g. This Agreement shall become effective and shall continue in force and effect as set
forth, hereto.
h. The individuals signing this Agreement (which shall include any other addendums
here to) warrant and certify by their signatures that this Agreement has been duly
approved and that they are authorized to sign this Agreement and all addendums
comprising this agreement on behalf of the respective party.
i. This Agreement may be executed in more than one counterpart, and each executed
counterpart shall be considered as the original, all of which together shall constitute
only one (1) Agreement.
j. This Agreement shall be governed by and construed and enforced in accordance
with the laws of the State of Arizona, and is subject to the provisions of A.R.S. §
35.511.
6. Compliance Requirements for A.R.S. § 41-4401, Government Procurement; E-Verify
Requirement:
a. FMC warrants compliance with all federal immigration laws and regulations
relating to employees and warrants its compliance with A.R.S. § 23-214,
Subsection A (that subsection reads: "After December 31, 2007, every employer,
after hiring an employee, shall verify the employment eligibility of the employee
through the E-Verify program and shall keep a record of the verification for the
duration of the employee's employment or at least three years, whichever is
longer").
b. A breach of warranty regarding compliance with immigration laws and regulations
shall be deemed a matenarbreach of -this Agreement and the Agreement may be
subject to termination.
c. For questions about E-Verify FMC should visit the following web site:
http://www.uscis.gov/portal/sitehiscis
Any notices or other communication permitted or required by this Agreement shall be in writing
and shall be delivered to the other party at the address set forth below:
If to PROGRAM: If to FMC:
Maricopa County Dept. of Public Health See Exhibit A for specific facilities
4041 N. Central Ave. Ste. 1400
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Phoenix, AZ 85012 With a copy to:
Attn: Joel Kodicek Renal Care Group Arizona, LLC "
Strategic Planning & Ops Supv c/o Fresenius Medical Care North America
920 Winter Street
With a copy to: Waltham, MA 02451
Jennifer Hernandez, MS, RDN
Dietetic Internship Director Attn: Law Department
MARICOPA COUNTY Renal Care Group Arizona, LLC
Acting by and for its Department of Public
Health
By: By:
Chairman, Date
Maricopa County Board of Supervisors Name:
Title:
Attest:
Date
Date
Approved as to Form Date
Deputy County Attorney
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EX_HIBIT A
Facility Locations
Renal Care Group-Tempe
1449W. Southern Avenue
Tempe, AZ 85282
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EXHIBIT B
Education and Training of Dietetic Interns Required Prior to Participation in a Clinical
Placement
A significant component of the education and training of an accredited Dietetic
Internship/Coordinated Program includes supervised practice where, under the supervision and
tutelage of RDIs, the Dietetic Intern is able to apply theoretical knowledge and practice skills
learned in the classroom in an actual treatment environment. Therefore, no specific education
requirements are set out here.
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EXHIBIT C
Informed Consent for Intern Intern Participation
Date of Request:
hereby give Renal Care Group Arizona, LLC, an affiliate of
Fresenius Medical Care Nortir America (hereinafter "FMCNA"), permission to disclose my
medical records or to share confidential medical information with or about my condition with
participating interns.
The intern(s) will be providing patient care through clinical observation and trainings at the facility
under the supervision of FMCNA staff. Such information disclosed or shared may include the
complete case history, copy of medical records and other information related to my treatment at
FMCNA. This release is valid for the duration of the internship program, but can be revoked by
written request at any time.
Specific information to be disclosed or shared:
P-urpose of releasetemship participant
Signature of Patient or Legal Guardian Witness
(if legal guardian, state relationship -
e.g. parent, power of attorney, etc.)
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EXHIBIT D
Documentation, Records, and Evidence to be furnished by PROGRAM prior to a Dietetic
Intern's Clinical Placement
1. Proof of a Tuberculosis PPD skin test with a negative result
2. Immunization history, including Tetanus, Hepatitis B, Influenza, Chicken Pox, Measles,
Mumps, and Rubella
3. OSHA Training, completed within twelve (12) months of the Dietetic Intern's Clinical
Placement
4. Bloodbome Pathogen Training, completed within twelve (12) months of the Dietetic
Intern's Clinical Placement
5. Appropriate documentation regarding Pre-Engagement Screening as described in Sections
3-e and 3-f of this Agreement
6. Health Care Provider CPR certification (if such certification is required by applicable state
laws, rules, or regulations)
7. A Confidentiality Agreement signed by the Dietetic Intern, a faun of which is attached to
this Agreement as Exhibit F
8. Appropriate Intern records or proof of completion of the courses to the curriculum set forth
in Exhibit B of this Agreement
9. A written assurance or assertion that the Dietetic Intern is not under or subject to any form
of academic probation or sanction, behavioral-related probation or sanction, or other
probation or sanction from the PROGRAM
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EXHIBIT E
Description of Permitted Activities
A Dietetic Intern may write a progress note in a patient's paper medical record after reviewing the
intended documentation with the RDI. The RDI is responsible for co-signing the Dietetic Intern's
notes in the medical record and for ensuring that all documentation regarding the patient's
psychosocial status, needs, interventions and outcomes are properly documented in a timely
manner
Dietetic Interns may provide input to the plan of care (POC) process with the interdisciplinary
team under the supervision of the RDI who is responsible for attending and participating in the
development of the POC, and co-signing the document that is developed, unless restricted or
prohibited by state regulations.
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EXHIBIT F
Confidentiality Agreement for Each Dietetic Intern
As an Intern undertaknag clinical education ("Clinical Placement") at a facility of Renal Care
Group Arizona, LLC ("FMC"), an affiliate of Fresenius Medical Care Holdings, Inc. d/b/a
Fresenius Medical Care North America ("FMCNA") (FMC shall be included into the defined term
FMCNA), I understand that FMCNA has a policy concerning the non-disclosure of its confidential
information, and that this policy creates expectations of and obligations for me. Furthermore, I
understand that I may observe protected health infointation (PHI) as it is defined under the Health
Infoimation Portability and Accountability Act of 1996 and the regulations promulgated
thereunder ("HIPAA"). I understand that FMCNA is sensitive to the requirements to protect PHI
under HIPAA. To evidence that understanding and in consideration of my Clinical Placement at
FMC and for the access provided to me by FMCNA, I agree as follows:
1. "Confidential Information" means all information relating to the business of FMCNA that has
not been released publicly by authorized representatives of FMCNA. Some examples of such
information include: trade secrets and know-how, inventions, marketing and sales programs,
employee, customer, patient and supplier information, patient medical records, financial data,
pricing information, regulatory and reimbursement strategies, operations and clinical manuals.
Confidential information also includes all information received by FMCNA under an
obligation of secrecy to another party.
2. I will handle any FMCNA Confidential Infoimation in accordance with the current FMCNA
Policy — "Confidential Company Information." During and after my Clinical Placement, I will
not use FMCNA Confidential Information without written authority from FMCNA (except as
required by my Clinical Placement). I will not remove any Confidential Information from
FMCNA premises, and will not take any photographs or recordings of any kind while on
FMCNA premises. Upon leaving FMCNA, I will return all Confidential Information to my
supervisor at FMCNA. I understand that my obligation as to FMCNA Confidential
Information continues even after I leave FMCNA. This obligation ends only when (i) FMCNA
has voluntarily disclosed the information to the public; (ii) the information has been developed
independently and made public by others; or (iii) the information otherwise lawfully enters the
public domain.
—3. I will not—use or disclose any PHI which I may observe or whicmay btherwise disclosed
or made available to me (except as required by my Clinical Placement). PHI includes, but is
not limited to, information created or received by a health care provider as well as any
infoimation that identifies an individual or that can be used to identify an individual, such as a
patient's name, date of birth, or medical condition.
Signature Date
Print Name
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