CoxHealth Ambulance Ride Along

Read the document below in full to be sure you understand all terms and conditions and how they affect your role while in the ambulance.
Fill in the information below the waiver. Then sign and submit.

CoxHealth Ambulance Ride Along

RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK

Please read this information carefully and be aware that in and participating in this activity, you will be expressly assuming the risk and legal liability and waiving and releasing all claims arising from and associated with this activity.

I, the undersigned have requested Lester E. Cox Medical Centers (hereinafter referred to as CoxHealth) for permission to ride along as a passenger in a CoxHealth ambulance while it is performing ambulance related functions including emergency medical services.

I recognize and acknowledge that there are risks of physical injury, including exposure to COVID-19, associated with participating in ambulance related functions and I voluntarily agree to assume the full risk of any injuries, illness, damages or loss, regardless of severity, that I may sustain as a result of participating in this activity. I further agree to waive and relinquish all claims that I may have (or accrue to me) as a result of participating in this activity against CoxHealth, their employees, agents, successors and assignees, while I am involved in this activity.

I additionally agree that while participating in the Ambulance Ride Along, I am not permitted to participate in any emergency medical services and may be asked to terminate my ride along activities at the sole discretion of the ambulance crew.

I acknowledge that many of the activities engaged in by the CoxHealth ambulance staff are non-public, private, and confidential matters as defined under Missouri statutes and under the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Therefore, I agree not to divulge or pass on any patient related information that I receive or obtain while participating in the Ambulance Ride Along. Furthermore, I agree not to conduct any video recording, photography, or audio recording of any medical services rendered to by emergency medical staff.

I agree to indemnify and hold harmless CoxHealth and its employees, agents or successors for any claimed damages that may arise from my divulging injuries and/or private health information obtained while participating in the Ambulance Ride Along.
By signing below, I affirm that I have read and understand this Waiver and Release of Claims prior to signing it, and I am aware that by signing this Release, I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators, successors and assigns may have against CoxHealth.

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