Volunteer Health Care Provider Program(VHCPP)

Volunteer Health Care Provider Program(VHCPP)

APPLICATION FOR A VOLUNTEER HEALTH CARE PROVIDERPROGRAM CONTRACT
MAKE SURE TO FILL OUT ALL BOXES TO FINISH FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Occupation*
FL License Number*
Individual providers applying for a VHCPP contract for sovereign immunity protection that are affiliated with a Professional Association (P.A.), the Florida Department of Health recommends a sovereign immunity contract be established to protect the P.A.
Please indicate if you would like a contract for your affiliated Professional Association.*

YesNoNot Affiliated
Signature*

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Date*

MonthDayYear
Printed Name of Professional Association*
FEI or Document Number*
Printed Name and Title of Corporate Officer/Director with Contract Authority*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
TO PROTECT CLIENTS, A ROUTINE CHECK OF THE CORPORATION NAME AND PROVIDER’S PROFESSIONAL LICENSE WILL BE MADE THROUGH THE FLORIDA DIVISION OF CORPORATIONS AND THE FLORIDA DOH DIVISION OF MEDICAL QUALITY ASSURANCE
License/Corporation Verification (For DOH Use Only)
Individual

Current Florida Health Professional License? Yes___ No___

License Status "Clear and Active"? Yes___ No___

Corporation

Active Florida Professional Association? Yes___ No___ N/A___

Verification Completed by : ___________________________ ____________

Signature of VHCPP Regional Coordinator Date
Return application form to: Mariely Mujica-Perez, Regional Volunteer Coordinator, Volunteer Health Services, P. O. Box 1305, Tavares, FL 32778 or Scan-Mariely.MujicaPerez@flhealth.gov Fax 352-589-6492
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Volunteer Health Care Provider Program(VHCPP)

MAKE SURE TO FILL OUT ALL BOXES TO FINISH FORM