PureView Health Center Board Application
The operations of PureView Health Center are governed by a Board of Directors. Terms of membership are three (3) years. The Board meets monthly and has the responsibility for the determination of service policies for PureView Health Center. There is no payment for service on the Clinic Board of Directors. Neither employees nor relatives of employees are eligible for Board Membership. At least 51% of the members must be consumers of health center services. Selection of the members is made by the Board on the basis of the required composition of the Board as defined in the federal requirements for Community Health Centers.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Home E-mail
*
example@example.com
Are you currently employed?
*
Yes
No
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Employment
Employer Name
Employer Address
Work Email
example@example.com
Position
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Service History
Have you served as a board member for another organization?
*
Yes
No
If yes, please describe your experience
Are you (or is a member of your family) a provider of health services?
*
Yes
No
Have you ever been found guilty of a crime involving the misuse of Medicare or Medicaid funds or fraud which resulted in your being barred from participating in Medicare or Medicaid programs?
*
Yes
No
Are you (or is a member of your family) employed by PureView Health Center?
*
Yes
No
Do you utilize PureView Health Center services?
*
Yes
No
If yes, which services have you utilized within the past year? (Check all that apply)
PureView Health Center in Helena
PureView Health Center in Downtown Helena
PureView Health Center in Lincoln
Healthcare for the Homeless
Why do you want to serve on this board?
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I certify the facts stated in this application are true and complete. I understand that, if selected, any misrepresentations shall be considered sufficient cause for dismissal from the Board. I understand Board meeting attendance is extremely important to operation of PureView Health Center. (Enter your full name as confirmation.)
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Submit
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