Medical Facility Confidentiality Agreement Sample - Free Download
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EASTERN MAINE COMMUNITY COLLEGE
MEDICAL RADIOGRAPHY PROGRAM
Confidentiality Agreement Form
This document serves as an agreement between ________________________(observer)
and __________________________________ (Medical Facility) for an observational
experience to assist in the decision-making regarding entrance into a medical radiography
program.
The observational experience will be held in the Radiology Department of the above-listed
medical facility. The participant will function under the guidance of a radiographer,
radiography program faculty member, or other facility designated preceptor. The observer
will not assist or interfere in the care of any patient. The observer will not have access to
any medical records during the observational experience.
The observer will not discuss any information about the patients whose procedures have
been observed to any persons outside the medical facility.
Should injury occur to the observer at any time while the observer is at the medical facility,
the observer will not hold the medical facility or Eastern Maine Community College liable for
this injury.
The medical facility reserves the right to terminate this Agreement without notice at any
time when the best interests of the patient are not being served.
________________________________ _____________________________
Student Signature Date
________________________________ _____________________________
Representative Signature Date
Medical Facility
Send this completed form and the “Observation Form” to the EMCC Admissions Office to
be included in your file. Maintain a copy for your records.
Eastern Maine Community College, Admissions Office, 354 Hogan Rd., Bangor, ME 04401
FAX: 207.974.4683 PHONE: 207.974.4680
Rev 9/09
