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Nurse Practitioner Preceptorship Application
Thank you for you for your interest in Shenandoah Medical Care Center preceptorship program.In order to be considered for NP Preceptee selection, all documentation from numbers 1 - 5 must be supplied to the NP Coordinator during the open application period.After applicants are selected to interview, they will be required to complete numbers 4 and 5 to remain eligible for selection.
As a student who is rotating in this health care setting and office practice, you have an ethical and legalduty to keep patient information confidential. Federal law known as the. Health Insurance Portability and Accountability Act of 1996 (HIPAA) forbids healthcare providers from disclosing patients' protected healthcare information, except upon written authorization by the patient or as otherwise permitted by the law.
Under the HIPAA Security and Privacy Regulations, hospitals and other healthcare providers are required to have the capacity to determine who is accessing their patients' protected healthcare information and to protect the privacy of that information. Failure to maintain patient confidentiality, accessing patient information without a need to do so for your work, or any other violation of policy, may result in disciplinary action against the student, resident or fellow.
Some general guidelines:
I have received and reviewed all information that I was given about patient privacy and confidentiality. I understand there are rules regarding the use and disclosure of patient protected healthcare information, and I agree to abide by such rules and keep protected healthcare information confidential. I understand there are both educational and legalpunishments if I violate this policy. I recognize that I may be immediately removed and excluded from this program, if I do not comply with this Confidentiality and Privacy Agreement.
Shenandoah Medical Care Center’s (SMCC) students shall behave ethically. A commitment to ethical professional practice includes an overarching principle that express our values, and standards that guide our conduct.
SMCC’s overarching ethical principles includes: Honesty, Fairness, Objectivity, and Responsibility. Students shall act in accordance with these principles and shall encourage others within the organization to adhere to them.
A Student’s failure to comply with the following standards may result in disciplinary action.
Each student has a responsibility to:
Each Student has a responsibility to:
V. Resolution of Ethical Conflict
In applying the Standards of Ethical Professional Practice, you may encounter problems identifying unethical behavior or resolving an ethical conflict. When faced with ethical issues, you should consider the following courses of action:
have received a copy of, read and agree to adhere to SMCC’s Statement of Ethical Professional Practice.
Acknowledgement and agreement:
“Confidential Information” includes information relating to:
I understand and agree as follows:
Nurse Practitioner Student Financial AgreementPrior to the start of the clinical rotation, all students must agree to the Student Financial Agreement. The Student Financial Agreement acknowledges that a signed contract creates a financial obligation to Shenandoah Medical Care Center. The agreement also clarifies, withdrawal and non-payment conditions. Any questions regarding the Student Financial Agreement can be directed to the Business Office at (561) 619-9510 and email@example.com.
I understand and agree that once I have signed the contract, I am solely responsible for the payment of the resulting tuition, fees, and any other charges that I have authorized to be posted my account. I fully understand, acknowledge and agree that regardless of any expected reliance by me on any third-party resource, including, without limitation, financial aid, employer reimbursements, scholarships, or any other external resource, I am and remain personally responsible for paying any and all balances due to Shenandoah Medical Care Center. This agreement constitutes a continuing agreement obligating me to pay all outstanding balances due Shenandoah Medical Care Center.Fee
Application Fee: Nonrefundable $40 – This includes processing and submission of university/school required documentation, such as collaborative agreement, practice/provider CV/resume, etc.Hourly Rate*: $12/hour, i.e. 50 hours required for course = 50 x 12 = $600 (excluding Application Fee)*50% of clinical hours’ fee is required to hold student’s spot prior to the start of the rotationWithdrawal Policy
Contract agreement creates a financial obligation to Shenandoah Medical Care Center. A refund is only effective upon receipt of an official notice. Registration, enrollment and document collection service fees will not be refunded once contact has been initiated with your program director. Once the student has completed at least one (1) hour of clinical hours, they will only be eligibility for a partial refund. Once the student has completed a quarter (1/4) of their required clinical hours, they can be refunded half of the financial obligation. Once the student has completed at least half of their required clinical hours, no refund will be allowed. Non-attendance is not a leave-taking from the program; therefore, the student is still required to submit payments as agreed upon.Failure to Pay & Collections for NonpaymentI understand that if my account should lapse into delinquent status, I will receive a sign off on clinical hours, and will not be allowed to return to the clinical experience until my bill is paid. Please note that it is Shenandoah Medical Care Center practice discretion to place delinquent accounts with an outside collection agency at the end of each term. I agree to reimburse Shenandoah Medical Care Center the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs and expenses, including reasonable attorney fees, that Shenandoah Medical Care Center incurs in such collection efforts.Authorization
I authorize Shenandoah Medical Care Center and their respective agents/contractors to contact me regarding my student account at the current and/or future emails and numbers that I provide for my cellular phone or other wireless device using automated telephone dialing equipment or artificial or pre-recorded voice or text messages.Acknowledgement
I hereby acknowledge that I have read this Agreement and fully understand it. By signing below, I am agreeing to be bound by all the terms of this Agreement, thereby obligating me to pay all outstanding balances that I may incur with Shenandoah Medical Care Center now and in the future.
Monday to Thursday : 9:00am – 5:00pmFriday : 9:00am – 1:00pmSaturday - Sunday : Closed