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Functional Holistic Healing Internship / Externship / Observership Application Form

Statement of a Drug-Free Workplace

  • Functional Holistic Healing is committed to maintaining a drug-free workplace.


  • The unlawful possession, use, distribution, dispensation, sale, or manufacture of controlled substances is prohibited on the office premises. Violation of this policy may result in the termination of the internship / externship / observership.


  • The illegal use of controlled substances can seriously injure users' health, adversely impair the performance of their responsibilities, and endanger the safety and well-being of the healthcare team and members of the general public.

Confidentiality Agreement

  • As an intern at Functional Holistic Healing, you may have access to “Confidential Information”. This agreement aims to help you understand your obligations regarding confidential information.

  • Federal and State laws and regulations, including HIPAA, the Joint Commission on Accreditation of Healthcare Organizations standards, and strict policies of our practice protect confidential information.

  • The purpose of these laws, regulations, standards, and policies is to ensure that confidential information will remain confidential - that is, that it will be used only as necessary to accomplish the purpose for which it is needed.

As an intern, you must strictly comply with HIPAA laws, Federal and state regulations, and policies governing confidential information.

  • Your principal responsibilities in this area are explained below.

  • You are required to read and abide by the confidentiality rules.

  • Anyone who violates these rules will be subject to discipline, which might include, but is not limited to, termination of internship / externship / observership. In addition, violation of these rules may lead to civil and criminal penalties and potentially other legal action.


As an intern, you may have access to confidential information, which includes, but is not limited to, information relating to:

1. Medical record information (includes all patient data, conversations, admitting information, demographic  information, and patient financial information).

2. Protected Health Information (PHI), as defined by HIPAA, includes, but is not limited to, names, all geographic subdivisions; all elements of dates (except year) for dates directly related to an individual, telephone numbers, fax numbers, electronic mail addresses, social security numbers, medical record numbers, health plan beneficiary numbers, account numbers, certificate/license numbers, vehicle identifiers, device identifiers, and serial numbers, web universal resource locators (URLs), internet protocol (IP) address numbers, biometric identifiers, including finger and voice prints, full face photographic images and any comparable images, and any other unique identifying number, characteristic, or code.

              3. Employee information (i.e., social security number, employment records, and disciplinary actions).

Practice information (i.e., financial and statistical records, strategic plans, internal reports, memos, contracts, quality and peer review information, and communications).

             4. Computer programs, client and vendor proprietary information, source code, and proprietary technology.


  • You are expected to comply with the following regulations at all times during your internship / externship / observership with Functional Holistic Healing Practice.

  • You will only use confidential information/data as needed/necessary to perform your duties as an intern.

  • You will not divulge, copy, release, sell, loan, review, alter, or destroy any confidential information/data except as properly authorized within the scope of your professional activities affiliated with the practice.

  • You will not misuse confidential information/data or be careless with it.

  • You will safeguard and not disclose your computer password or any other authorization allowing you to access confidential information/data.

  • Functional Holistic Healing and Dr. Nadia Ali reserves the right to monitor your access to the network, including your account, if deemed appropriate. Functional Holistic Healing can revoke your access code or any other authorization allowing you to access confidential information/data at any time if necessary.

  • You accept responsibility for all activities using your assigned access code and/or other authorizations.

  • You will report activities by any individual or entity that you suspect may compromise the confidentiality of information.

  • You understand that your obligations under this Agreement will continue after your affiliation with the practice terminates.

  • You understand that any of your access privileges to confidential information/data are subject to periodic review, revision, and, if necessary, modification and/or termination.

  • You understand you have no right or ownership interest in confidential information/data.

  • You will be responsible for your misuse or wrongful disclosure of confidential information and for failing to safeguard confidential information/data, your password, or any other authorization that allows you to access confidential information/data.

  • Functional Holistic Healing may take disciplinary action against you up to and including termination if you violate this Confidentiality Agreement. In addition, it may initiate legal action, including but not limited to civil litigation or criminal prosecution.

  • You understand that Functional Holistic Healing reserves the right to monitor and record all network activity, including email, with or without notice, and therefore, users should have no expectations of privacy in using these resources.

Medical Staff

Code of Conduct Policy Statement

  • The intern will provide his/her own transportation.

  • The intern will report on time and as scheduled.

  • The intern will dress professionally.

  • The intern will comply with applicable safety regulations before and during their internship / externship / observership.

  • Comply with safety guidelines and policies. 

  • Termination for Cause. Functional Holistic Healing may terminate any intern upon the occurrence of any of the following:

  • Conduct by an Intern that could affect the quality of professional services provided to Company customers or be adverse to the best interest and welfare of the Company or its customers;

  • Breach of any of the confidentiality provisions hereof, including but not limited to HIPAA and the Student Confidentiality Agreement, or of Company policy;

  • Illegal possession or use of controlled substances.

  • The intern is convicted of a criminal offense.

Safety Policy

  • Accident prevention is the responsibility of all interns.


  • Functional Holistic Healing will strive to provide a safe and healthy workplace environment for all.


  • Intern must accept and follow all established safety regulations and procedures.


  • Unsafe conditions must be reported immediately to the supervisor.


  • If you are not sure of how to perform a task safely, he or she should ask a qualified person for guidance or help. If someone needs help to perform a task safely we will provide assistance. Safety is a team effort.


  • Every injury must be reported immediately. Even a slight cut or strain injury must be reported immediately to your supervisor. Do not leave the job site or clock out before reporting the accident or injury.


  • Serious injuries that require emergency medical care must be reported to the supervisor immediately after emergency care has been provided.


  • All accidents will be thoroughly investigated to assess the root cause and prevent future accidents.


  • Interns must cooperate with management during any accident or injury investigation.


  • Gloves must be worn whenever any vascular access procedure is performed, including phlebotomy.


  • Gloves are required when giving an injection since there is a possibility of hand contact with blood or other potentially infectious materials.


  • Bending, recapping, or removing contaminated needles is prohibited.


  • Dispose of all sharps in the sharps container.

  • Handwashing or Antiseptic hand cleansers in conjunction with clean cloth/paper towels need to be used after any procedure where physical contact with blood or other infectious material is anticipated.


  • Sharps containers shall be maintained upright throughout use, replaced routinely, and not be allowed to overfill. When removing sharps containers from the area of use, the containers shall be:


Closed immediately before removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping Placed in a secondary container if leakage is possible. The second container shall be:


  • Closable;

  • Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping; and

  • Labeled or color-coded

Organizing Test Tubes

Patient Interaction Guidelines

  • The patients’ that are coming through Functional Holistic Healing will not be contracted directly without the exclusive permission of the Functional Holistic Healing. Inability to comply will be considered a cause for termination.

  • All the forms that are provided for patient assessment, education and documentation are the sole property of ‘Functional Holistic Healing’. These cannot be copied, downloaded or produced without the sole permission of Functional Holistic Healing.

Online Medical Consultant

Attendance and Punctuality Policy

Timely and regular attendance is an expectation of performance for all. To ensure that we serve our patients efficiently and effectively, we need to take responsibility for being on time.


If an intern cannot meet this expectation, he/she must obtain approval from their supervisor (Dr. Nadia Ali) before any requested schedule changes. The request needs to be emailed to the physician.

This approval includes requests for late arrivals to or early departures from work.

Once the request is approved, it needs to be reflected on the schedule. The intern is responsible for the request being added to the schedule, and everyone knows it.

If there is an emergency and you cannot be on time for some urgent reason, you must inform the physician as soon as possible.

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