VIM Provider Application

VIM Provider Volunteer Application

Please complete this application to volunteer as a doctor with VIM. All information is confidential and used for onboarding and credentialing. For questions regarding our credentialing process, please contact credentialing@vimclinic.org
Applicant Information
Full name*

First NameLast Name
Preferred name
Date of birth*

MonthDayYear
Date
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Home address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency contact name*
Emergency contact relationship*
Emergency contact phone*
Please enter a valid phone number.Format: (000) 000-0000.
Professional Credentials
Medical degree *
Specialty / primary discipline*
State(s) of licensure + license number(s) + expiration date(s)*
DEA number
DEA expiration date

MonthDayYear
Date
NPI
Board certification(s)

Internal MedicineFamily MedicinePediatricsSurgeryOther (please specify)
Years in practice*
Are you currently in good standing with all licensing boards?*

YesNo
Have you ever been subject to disciplinary action, restriction, suspension, or investigation by a medical board, hospital, or employer?*

YesNo
If yes, please explain:
Volunteer Role Preferences
Areas you can support*

Primary careUrgent careProceduresTelehealthTriagePatient educationQuality improvementSpecialty clinic (please specify)Other (please specify)
Languages spoken and proficiency
Are you willing to supervise trainees/assist with teaching?*

YesNoMaybe
Availability
Preferred volunteer frequency*

MonthlyTwice a monthWeeklyAs needed
Days of week available*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Time of day available*

MorningAfternoonEvening
Date you can start*

MonthDayYear
Date
Any planned time away in next 6 months
Compliance & Requirements
Can you provide proof of medical license and photo ID?*

YesNo
Will you complete onboarding/training and required policies?*

YesNo
Do you consent to a background check?*

YesNo
I acknowledge the HIPAA/confidentiality agreement*

I acknowledge and agree to maintain patient confidentiality in accordance with HIPAA and VIM policies.
References & Documents
Upload your CV or Resume*

Cancelof
Upload a copy of your medical license*

Cancelof
Upload a government-issued photo ID*

Cancelof
Optional: Upload malpractice coverage declaration / face sheet

Cancelof
Professional Reference 1*
Professional Reference 2*
Additional Information
Why do you want to volunteer with VIM?*
Describe any relevant experience working with underserved populations*
Do you require any accommodations to volunteer?
Attestations & Signature
I certify that the information provided is true and complete.*

I agree
Type your full name as electronic signature*
Signature date*

MonthDayYear
Date
Should be Empty:

VIM Provider Volunteer Application

Applicant Information

Professional Credentials

Volunteer Role Preferences

Availability

Compliance & Requirements

References & Documents

Additional Information

Attestations & Signature