Clinical Rotation Application

The County of San Mateo Health System will only accept clinical rotation applications from students and residents attending schools with which we currently have established agreements.  

To ensure proper consideration, please fill in the information below as completely and accurately as possible.

Personal Information

calendar

Rotation you are requesting

calendar
calendar

Professional School or Program you are currently attending

Professional School or Residency Program

Agreements and Signatures

APPLICATION SIGNATURE
 
I fully understand that any significant misstatement in or omission from this application will constitute cause for denial, or revocation of my priveleges to be at the County of San Mateo Health System.  I hereby affirm that the information furnished by me is true and complete to the best of my knowledge and is furnished in good faith.  I present this request in the expectation that the confidentiality and privacy of this information will be preserved, and that this information and these materials will only be released or disclosed as part of current and future credentialing, peer review, and quality assurance processes.
calendar
Signature *
clear
 
CONFIDENTIALITY STATEMENT
Voluntary Placement

In order to preserve the dignity and privacy of individual human beings, it has been recognized that any intimate information known by or given to a minister, a lawyer, or to a doctor or hospital is so privileged that such information is protected under law with prescribed methods, circumstances and penalties for its release.

In accepting placement/assignment/rotation at the County of San Mateo Health System/San Mateo Medical Center, you have accepted a responsibility that carries with it a privilege of service to our System/Center.  You are an integral part of the Health System/Medical Center team(s) and accept the same ethical responsibility as the Health System’s/Medical Center’s professional staff.  All information you may hear, directly or indirectly concerning a patient, a doctor, or any member of the Health System’s/Medical Center’s personnel, MUST BE CONSIDERED AS STRICTLY CONFIDENTIAL.  Such information should never be discussed with anyone either inside or outside the Health System/Medical Center.  Confidential information includes photographs, fingerprints, recording, or tape recordings of patients’ voices, or any means of identifying the patient.  This responsibility has its greatest impact with respect to friends or acquaintances you may see or otherwise gain knowledge of while working in this Health System.

By checking the box below, I agree not to divulge any information obtained during my tenure at the County of San Mateo Health System/San Mateo Medical Center to unauthorized persons.  I recognize that unauthorized release of confidential information may make me subject to a civil action under provisions of the Welfare and Institutions Code of the State of California and applicable Federal laws concerned with the individual’s right to privacy.

 *

CORPORATE COMPLIANCE SMMC CODE OF CONDUCT

I recognize and am fully dedicated to advancing SMMC’s commitment to full compliance with all Federal, State and other governmental health care program requirements, including its commitment to prepare and submit accurate claims consistent with such requirements.

I will comply with all Federal, State or other governmental health care program requirements and with SMMC’s policies and procedures relating to SMMC’s Corporate Compliance Program, including the requirements set forth in the Corporate Integrity Agreement (CIA) to which SMMC is party.

I will promptly submit accurate information for Federal health care cost reports including, but not limited to, the requirement to submit accurate information regarding acute available bed count for Disproportionate Share Hospital (DSH) payment, if my job duties require me to submit such reports.

I will report to the Compliance Officer and my supervisor any suspected violation of any Federal health care program requirements or of SMMC’s Compliance Program policies and procedures.

I have the right to use the Disclosure Program by calling the Compliance Hotline or reporting incidents to the Compliance Officer.  SMMC is committed to non-retaliation and will maintain, as appropriate, confidentiality and anonymity with respect to such disclosures.

I understand that non-compliance with Federal health care program requirements and SMMC’s Compliance Program policies and procedures, and failing to report such violations, could result in disciplinary actions up to and including termination.

I am responsible for acquiring sufficient knowledge to recognize potential compliance issues applicable to my duties and for appropriately seeking advice regarding such issues.

I will not offer or give nor accept any bribe, payment, gift, or thing of value to any person or entity with whom SMMC has or is seeking any business or regulatory relationship.  I will promptly report the offering or receipt of gifts to my supervisor or the Compliance Officer.

I will not engage in any financial, business, or other activity which competes with SMMC/County business which may interfere or appear to interfere with the performance of their duties or that involve the use of Company property, facilities, or resources, except to the extent consistent with the SMMC/County Incompatible Activities and Outside Employment policy.

I will cooperate fully and honestly with internal audits and monitoring programs to help assure that our compliance is maintained with all applicable federal/state regulations, the Joint Commission standards, and hospital system-wide policies.

TO REPORT VIOLATIONS, CALL THE COMPLIANCE HOT LINE: (800) 965-9775

By clicking, “I Agree” below, I certify that I have received this Code of Conduct, that I understand it, and that I will support it.

 *
 

ACKNOWLEDGMENT OF SMMC’s COMPLIANCE and HIPAA PROGRAM

As a provider of services at SMMC,

  1. I am responsible for acquiring sufficient knowledge to recognize potential compliance and HIPAA issues applicable to my duties and for appropriately seeking advice regarding such issues.
  2. I understand that the False Claims Act (FCA) is the government’s primary weapon to fight fraud.
  3. I will abide by SMMC’s policies to ensure that I do not violate the FCA and the Stark Law.
  4. I will recuse myself from any potential conflict of interest situation.
  5. I will voluntarily disclose anytime I am listed on the OIG exclusion list.
  6. In regards to HIPAA, I understand new California legislation has made it easier to fine organizations and prosecute individual violators if they are found to have unlawful or unauthorized access to, and use or disclosure of PHI.
  7. I understand failure to comply with County policies and procedures may lead to disciplinary action and/or termination.
  8. I will report any HIPAA breach to the Privacy Officer as soon as an incident is known to have occurred.
  9. I will report any compliance violations to the Medical Staff Office and Compliance Officer.

By clicking, “I Agree” below, I certify that I have read and understood the directives on SMMC’s Compliance and HIPAA Program set forth by the Federal, State and the County of San Mateo, and that I will support it.

 *

San Mateo County Health System DECLARATION OF NOTICE OF CONFIDENTIALITY

As an employee, contractor, or associate of San Mateo County Health System, I agree to the following as evidenced by my signature affixed below:

I will not disclose or otherwise discuss the  Health System’s patients or clients, their conditions, treatments or status, even if they are known to me personally, with anyone, except to carry out my assigned duties associated with their proper care or treatment.

I will not release information to any one concerning the financial, medical, or social status of Health System’s patients or clients which has not first been authorized according to written Health System policies, federal or state regulation, or otherwise properly ordered by legal authorities.

I will not, at any time or under any circumstances, disclose or share any of the Health System’s assigned computer system User Identification or password to anyone.

I will not tamper with any Health System’s computer system to gain unauthorized access to the network or information contained there.

I will take all reasonable care to prevent the unauthorized use, disclosure or availability of confidential and/or proprietary information through unattended screen displays or by mishandling of system generated output, regardless of its form.

I acknowledge that the Health System retains the right to monitor and/or review, at any time and without cause, any access to Health System computer services for evidence of tampering or misuse, and may, at its sole discretion, suspend or terminate Health System computer privileges pending administrative review.

I agree to adhere to policies concerning Health System’s computer services and understand that any misconduct and/or breaches of confidentiality expressly described herein may be grounds for immediate suspension of computer privileges.  In addition, Health System’s administrative actions, up to and including termination of employment or contract may result.  Additionally, violation of any applicable civil or criminal statutes by the disclosure of confidential material or information or other misuse of the computer system will be prosecuted to the fullest extent of the law.

This agreement constitutes the entire agreement with respect to any confidential and/or proprietary information and will supersede any prior agreement.

If you agree with all of the statements above, please click the “I Agree” button below.

 *

Health Information Uploads- This information is required in order to approve your application to do a clinical rotation at San Mateo County Health or the San Mateo Medical Center.