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Academic Affiliations

Affiliated Student Attestation Form

I certify that I have read and completed all the requirements of the University of Mississippi Medical Center (UMMC) Orientation information. I understand that I am required to comply with all hospital policies and the directions of the supervising physician, nurse or other personnel.

I certify that I have read and completed all of the requirements of the UMMC HIPAA Compliance Training. I understand that I am required to maintain confidentiality of all patient information to which I have access.

I certify that I have read and understand the UMMC Information Policy. As an individual having access to UMMC information on or off campus, I agree to abide by the UMMC Information Policy and all other institutional policies. I understand that non-compliance will be cause for disciplinary action up to and including system privilege revocation, dismissal from UMMC, and possible criminal and/or civil penalties.

I understand that I will not be considered to be an employee of UMMC and agree that I will not be compensated financially. I also understand that I am not entitled to any benefits available to UMMC employees.

I agree to conduct myself in a professional manner at all times while on the UMMC campus and will support the hospital's mission of providing model care.

* = Required Fields

Please select the UMMC area/discipline for your affiliated student placement:*
Name* 
School* 
Program* 
UMMC ID #*  
Date*  
By checking the following box, I certify that I have completed the requirements stated herein and agree to all terms.*