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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 acknowledge that I have received, read and understand the security policies in the UMMC Information Technology Acceptable Use Policy. I understand and agree to comply with all policies, standards, and procedures adopted to safeguard information and associated information resources as set forth in the Mississippi Code and UMMC policies. I understand that failure to comply with any of the conditions noted herein may result in disciplinary action, including possible dismissal and termination. I further understand that UMMC retains the right to pursue any other legal remedies available when misuse of its information and/or information resources is suspected.

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.

For current UMMC employees only:
I understand that the affiliated student placement is separate from my UMMC employment and must occur outside of any paid UMMC work hours.  I certify that I will obtain a second UMMC ID badge and wear at all times during the affiliated student placement to identify myself to patients, faculty, and staff as a student in training. I understand that access to the medical record during the affiliated student placement must occur in the assigned Epic affiliated student role.

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By checking the following box, I certify that I have completed the requirements stated herein and agree to all terms.*