Medical volunteer application

Licensed Volunteer Healthcare Professional Application

It is the mission of CCMC to improve life for our under-served, under-resourced neighbors by address physical, mental, and spiritual health; practical concerns and needs; and by disrupting poverty. Volunteer healthcare professionals are protected from civil suits in accordance with the "Volunteer Licensed Healthcare Professional Immunity Act." Our medical clinic, pharmacy, dental, and visions services are staffed by licensed healthcare professionals and administrative volunteers. For more information, please contact Theresa Milroy, Clinic Coordinator at tmilroy@ccmchs.org or Sallie Culbreth, Executive Director at sculbreth@ccmchs.org or call 501-318-1153.
Medical Volunteer Information
Name*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Languages fluently spoken in addition to English
Are you a licensed medical professional?*

YesNo
What is your medical professional status?*

RetiredActive but not retiredSemi-retiredOther
Work/Occupation/Area of Expertise*
Please list credentials and licenses that you hold*
My license with the State of Arkansas is current and in good standing:*

YesNo
Please upload a copy of your license with the State of Arkansas*

Browse Files

Cancelof
I am considered in good standing with these states:
Emergency contact person*

First NameLast Name
Emergency contact phone number*

Area CodePhone Number
Do you have Professional Malpractice Insurance?

TailsSVMICEmployer provides professional malpractice insuranceOther
Scope of Care
Type of Provider*
If Other, please explain
Specialty or Care Area*
If Other, please explain
What type of patient care experience do you have?

VentilatorsPalliative CareVasopressor dripsIntubationDialysis machines (CRRT or CVVH)Central linesInserting IVsGeneral medical inpatient careGeneral medical outpatient careLabor & DeliveryMedication preparation / hanging dripsOther
Please indicate highest level of patient care*
Work Status*
Matching with Need
Number of Days per week you can volunteer*

12
Days of week you can volunteer*

WednesdayThursday
Please indicate highest number of hours you are able to work in a day
Agreements

Confidentiality, Background Checks, and Volunteer Status
CONFIDENTIALITY STATEMENT

I acknowledge that this statement applies to all members of the workforce, including but not limited to, employees, volunteers, students, physicians, resident physicians, and third parties, whether temporary or permanent, paid or not paid, visiting, or designated as associates, who are employed by, contracted to, or under the direct control of Cooperative Christian Ministries and Clinic.

I acknowledge that CCMC has formally stated its commitment to preserving the confidentiality and security of health information, whether it is maintained or distributed in paper, electronic, video, verbal, or any other medium or format. I understand that I am required, if I have access to such health information, to maintain its confidentiality and security.

I understand that access to health information created, received, or maintained by CCMC is limited to those who have a valid business or medical need for the information or otherwise have a right to know the information. I understand that there are many administrative, physical, and technical safeguards in place to protect the privacy and security of this health information, and that any attempt to bypass or override these safeguards is in violation of federal and state laws and the privacy and security policies of Cooperative Christian Ministries and Clinic.

I understand that anyone who is authorized to access electronic health information with CCMC will be issued a unique user identification and password, and that any person who knowlingly discloses their user ID or password to others, uses or discloses another individual's user ID or password, or accesses any electronic protected health information without authorization is subject to disciplinary action, up to and including dismissal. In addition, I understand that all CCMC and affiliate workforce members must comply with applicable Information Technology Security Policies.

I further understand that with the exception of purposes related to treatment, access to, uses and disclosures of, and requests for an individual's health information must, to the extent practicable, be limited to the minimum necessary to accomplish the intended purpose of the approved use, disclosure, or request.

I understand that any known or suspected violations of the confidentiality or security of health information must be reported to my immediate supervisor or to the Privacy Officer (CCMC Administrator) immediately.
AUTHORIZATION TO OBTAIN CRIMINAL BACKGROUND REPORTS

I authorize CCMC to obtain criminal background reports and/or investigative criminal background reports for background investigation. I understand that these reports might include, but are not limited to, a search of my criminal background, reference checks, driving record checks, and verification of my identification and Social Security Numbre. I agree that this Disclosure/Authorization, in original or copy form, is valid for all current and future criminal background reports.
VOLUNTEER STATUS

I understand that as a Licensed Healthcare Professional that my work at CCMC is purely volunteer. I understand that there is no compensation for my services. CCMC receives no third party insurance.
Signature*

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Date*

MonthDayYear
Date
You will be contacted soon to set up an appointment to meet with CCMC Clinic Coordinator and Executive Director. Thank you for your willingness to serve as a Volunteer Licensed Heathcare Professional.
CCMC 133 Arbor Street Hot Springs, AR 71901

info@ccmchs.org 501-318-1153 https://ccmchs.org

2023
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Licensed Volunteer Healthcare Professional Application

Medical Volunteer Information

Scope of Care

Matching with Need

Agreements