Volunteer Profile Application

Name*

First NameLast Name

Middle Initial

Date of Birth*

Date

Mailing Address*

City*

State*

Zip*

Home/Cell Phone*

Email address*

example@example.com

Work Phone

Best time to call?*

Employer/School*

Occupation/Previous Occupation*

In Case of Emergency Contact*

Relationship w/ Emergency Contact*

Emergency Contact: Address*

Emergency Contact: Telephone*

Please select all available times you may be able to volunteer at NNMFHC

Morning (9am - 12:30pm)

Afternoon (12:30pm - 4:30pm)

Evening (4pm - 8pm)

TuesdayThursday

Please select all areas of special interest you may want to work with

If you selected Nursing, Physician, Pharmacist, or Dentist, please select the specialty you indicated in the field above and enter your license number*

Please indicate any previous work experience*

List any previous experience in volunteer organizations*

Patient Confidentiality Agreement

Because of the nature of the Clinic's work, it is imperative that information pertaining to patients is kept confidential. All applicable Health Insurance Portability and Accountability Act (HIPAA) and other legal standards and requirements will be complied with. This policy applies to volunteers as well as board and staff members of the Northern Neck Middlesex Free Health Clinic.

Under no circumstances are patients to be discussed outside the Clinic. Within the Clinic, cases should be discussed only with those directly involved.
Joint conferences to discuss patients must be held in private and on a "need to know" basis.
All information about patients, their illnesses or their personal lives must be kept in strict confidence.
Access to patient records is restricted only to those who have a specific reason, in accordance with applicable law, to read the charts.
Conversations with patients at the front desk, nurses' station, lab, exam room and elsewhere must be held in a way that protects the patient's privacy and confidentiality. When talking with a patient on any matter, it should be done in a way that other patients cannot overhear.
Case histories, confidential papers and appointment books should not be kept in plain view.
Do not give advice to patients on personal matters, even if they ask for it, and do not reveal patient information even to the patient's family members.
If patients ask about their own cases, refer them to a medical provider.
Since medical information by a provider is confidential, no patient information will be provided to outside agencies except with the patient's written consent or as permitted by applicable law.

Volunteer Electronic Signature

Date

Responsible Party Electronic Signature

If volunteer is under 18 years of age

Date