Reappointment: Licensed Voluntary Service Provider


Thank you for applying for reappointment. All questions must be answered. If you need more space to provide answers, please include your responses in the Additional Information section. If a question does not apply to you, please mark it as n/a.

  1. IDENTIFYING INFORMATION
  2. LICENSURE
  3. BOARD CERTIFICATION
  4. HEALTH STATUS
If the answer is "NO" to either of the following questions, include details as an attachment.
If "NO" or if reasonable accomodation is required, please explain in Additional Information section.
If "NO" or if reasonable accomodation is required, please explain in Additional Information section.
  5. 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Have any of the following ever been, or are currently being, denied, revoked, suspended, relinquished, withdrawn, reduced, limited, placed on probation, not renewed, or currently under investigation?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 in Attachment "A" Malpractice Claims Questionnaire.
  ATTACHMENT "A": MALPRACTICE CLAIM / SUIT QUESTIONNAIRE
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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