Volunteer Application Form

Name*

First NameLast Name

Phone Number*

E-mail*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Areas I would like to help

I would like to volunteer on (select all that apply)

Times available

MorningsAfternoonsAll dayOther

How did you hear about us?*

VOLUNTEER AGREEMENT AND CONFIDENTIALITY STATEMENT PCHS agrees to the following:

- Provide instructions relating to the volunteer's services and activities.
- Provide supervision for the services and activities to be performed.

- I understand that by signing below that I am volunteering for personal reasons, without promise or expectation of compensation, benefits, or future employment from PCHS. I acknowledge that I have neither been promised any consideration or compensation, nor do I expect to receive any consideration in return for my services.
- I agree to familiarize myself with and abide by PCHS' rules and policies, including those relating to conduct, safety, dress code, technology use, and confidentiality. I understand that in order to volunteer, I may be subject to a background check and other screenings as required by PCHS.
- I understand that PCHS offers me no employment compensation or benefits as a part of this Volunteer Agreement. I acknowledge that my volunteer position can be terminated at any time by myself or PCHS.

NON-EMPLOYEE CONFIDENTIALITY AGREEMENT
Pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended by the HITECH Act and privacy and security rules promulgated thereunder ("HIPAA"), Peninsula Community Health Services
("PCHS") is responsible for safeguarding patients' protected health information ("PHI"). This Agreement is intended to ensure that PCHS' contractors' representatives and other non-employees ("Non-Employees") understand their responsibilities when accessing, using, or otherwise encountering any PHI or other confidential information as described below.

Confidential information ("CI") means any information that is non-public, medical, financial, personal, or proprietary. This includes information in any form that is: (i) commonly regarded as confidential in the healthcare industry, and (ii) PHI as defined by HIPAA. Non-Employees will or may access, use, or encounter CI relating to the healthcare of PCHS' past, present, and future patients. As a condition of accessing PCHS' premises, networks, and/or technology, including PCHS' Electronic Health Record, Non-Employee understands and agrees:

--Non-Employee must maintain and safeguard any and all CI.

--Non-Employee shall not access, use, or disclose CI unless a Business Associate Agreement (BAA) has been signed between the Non-Employee's company and PCHS or as otherwise permitted by federal and Washington State law.

--Any authorized access to CI may be monitored to assure appropriate compliance with system integrity and PCHS' policies and procedures.
Unauthorized access, use, or disclosure of CI may result in: (i) immediate removal from the premises/PCHS' systems; (ii) liability to the individual and/or Company; and (iii) this Agreement and any existing agreements being terminated.