Confidentiality Statement
Emergency Medical Services Program
Throughout the Emergency Medical Services Program at Indian Hills Community College,
I, ______________________________, will have access to patient information. I realize that this information is
private and should be kept confidential. I realize that any unauthorized release of information is punishable by fine
and/or imprisonment or dismissal from the program.
Throughout my education in the Emergency Medical Services Program at Indian Hills Community College, I will
not at any time inappropriately release confidential information and I will adhere to the Code of Ethics of the
Emergency Medical Services Program.
I understand that release of unauthorized patient information will result in immediate termination from the Indian
Hills Community College Emergency Medical Services Program.
Name:
Signature: Date:
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