Healthcare Mentorship Agreement

HEALTHCARE MENTORSHIP AGREEMENT

Parties and Contact Information

Agreement Effective Date and Term

This Healthcare Mentorship Agreement (the Agreement) is entered into on by and between the Mentor and the Mentee identified above. The initial term of this Agreement shall commence on the effective date and continue until unless earlier terminated as set forth herein.

Scope and Purpose

The Mentor agrees to provide career and clinical mentorship, professional development guidance, and feedback to the Mentee. The parties acknowledge that this Agreement creates a professional mentoring relationship and does not establish a clinical supervisory relationship, medical staff privileges, or delegated authority for the Mentor to manage patient care. The Mentee retains sole responsibility for clinical decisions made in patient care environments.

Mentor and Mentee Responsibilities

Mentor Responsibilities include providing regular guidance, reviewing de-identified clinical cases when permitted, offering career counseling, sharing educational resources, and providing constructive feedback. Mentor will act within the scope of their professional licensure and will not provide direct clinical orders or assume clinical responsibility for the Mentee's patients.

Mentee Responsibilities include attending scheduled mentorship sessions, preparing case summaries in accordance with privacy obligations, seeking and obtaining any required patient authorizations prior to disclosure of protected health information, implementing agreed professional development actions, and assuming full responsibility for all clinical care decisions.

Meetings, Format and Frequency

Meetings shall occur with the following frequency: and in the agreed format: . Either party may propose changes to the schedule with reasonable notice.

Confidentiality, HIPAA and Patient Information

The parties acknowledge applicable privacy laws and regulations governing protected health information. Unless valid written patient authorization is obtained, the Mentee must de-identify patient information before sharing for mentorship purposes. The Mentor and Mentee each agree to maintain confidentiality of all protected health information and to implement administrative, physical and technical safeguards consistent with applicable law.

By checking the box below, the Mentee affirms that any shared patient information will be de-identified or accompanied by a valid patient authorization as required.

I acknowledge and agree to de-identify patient information or obtain valid authorizations prior to disclosure.

HIPAA / Privacy Authorization Expiration Date:

Recording and Use of Materials

Sessions may be recorded only with the express written consent of both parties and in compliance with applicable privacy laws. Recordings, notes, educational materials, and case discussions remain confidential and may not be distributed outside the mentoring relationship without prior written permission.

I consent to audio/video recording of mentorship sessions under the terms described above.

Compensation and Expenses

Compensation for mentorship services (if any) shall be: Paid (enter amount) Not Paid

Reimbursable expenses must be pre-approved in writing by the paying party.

Liability, Indemnification and Insurance

The Mentor provides educational and professional guidance only and does not assume responsibility for patient care. The Mentee agrees to indemnify and hold harmless the Mentor from claims arising from the Mentee's professional acts or omissions. Each party is encouraged to maintain professional liability insurance as appropriate to their practice.

Termination

Either party may terminate this Agreement for any reason upon days' written notice to the other party. Termination does not relieve either party of obligations accrued prior to termination, including confidentiality and indemnity obligations.

Miscellaneous

This Agreement constitutes the entire agreement between the parties regarding mentorship and supersedes prior discussions. Amendments must be made in writing and signed by both parties. If any provision is held invalid, the remaining provisions shall remain enforceable. This Agreement shall be governed by the laws of the state specified below.

Acknowledgment

By signing below, the parties certify that they are authorized to enter into this Agreement, that they have read and understand its terms, and that they will comply with all applicable laws and professional standards in the performance of their respective obligations hereunder.

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