Licensed Voluntary Service Provider


Thank you for your interest in volunteering with the Coachella Valley Volunteers In Medicine clinic! Our ability to provide care is determined by the number of medical and dental providers such as you who give so freely of your time. Before completing our application please consider some of our requirements to be a volunteer:

  1. All licensed providers, regardless of your profession, must be licensed to practice in the State of California.
  2. All licensed providers are credentialed, a process that can take up to 8 weeks. Generally, you are not allowed to provide care at our Clinic until this process is completed.
  3. Prior to submitting your application, we generally require you to shadow a current provider to experience firsthand some of what you will encounter as a provider.
  4. If you decide to proceed with an application, we require a commitment to volunteer a minimum of 4 hours per month, for a minimum of at least 6 months.

If you are interested in continuing with your application, please answer the following questions to help us better meet your needs and desires.

  INTEREST
  APPLICATION TYPE
  IDENTIFYING INFORMATION
  LICENSURE
  PROFESSIONAL EDUCATION
  POST-GRADUATE TRAINING: INTERNSHIP(S)
  BOARD CERTIFICATION
  HEALTH STATUS
If the answer is "NO" to either of the following questions, include details in the Additional Information field.
If "NO" or if reasonable accomodation is required, please explain in Additional Information field.
If "NO" or if reasonable accomodation is required, please explain in Additional Information field.
  DISCIPLINARY and/or VOLUNTARY ACTIONS
Have any of the following ever been, or are currently being denied, revoked, suspended, relinquished, withdrawn, reduced, limited, placed on probation, not renewed, or currently under investigation?
If “yes” please provide details on Attachment “A” – Malpractice Claims Questionnaire
  ATTACHMENT "A": MALPRACTICE CLAIM | SUIT QUESTIONNAIRE(S)
If you answered YES to Question 12 of DISCIPLINARY and/or VOLUNTARY ACTIONS of this application, please complete the following questionnaire for EACH CLAIM or SUIT. If you need to report more than one incident, please use the Additional Information field following the questionnaire.
  ADDITIONAL INFORMATION
  REQUEST TO PROVIDE VOLUNTARY SERVICES
By my signature below, I acknowledge that I have the burden of producing information requested by Coachella Valley Volunteers in Medicine for proper evaluation of my professional training, experience, competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I further acknowledge and agree that I will promptly and fully report all information to the CVVIM clinic in the event any of the answers above change, or if any situation arises which affects my ability to treat patients, after I have signed and dated this form. All the information contained in this application is complete and accurate to the best of my knowledge. I pledge that I am free from any chemical dependency and physically and mentally able to practice medicine and perform the volunteer services I have requested. I agree to abide by clinic policies and procedures as from time to time may be revised or enacted.
  CONSENT FOR RELEASE OF INFORMATION
I hereby authorize Coachella Valley Volunteers in Medicine or their representatives, to consult with any entities or persons that may have information relative to my professional practice. A photocopy of this waiver shall be as effective as the original when so presented. This consent shall remain in full force and effect for a period of two (2) years from the date signed below. I hereby release from any liability all those who, in good faith, review, act on, or provide information regarding my competence, training, experience, professional ethics, character, health status, and other qualifications, for providing volunteer services. I understand that the completion of this application is my sole responsibility. I declare that the information furnished by me in this application is true and correct to the best of my knowledge.
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