Voluntary Service Provider (Medical) Application | Volunteers In Medicine

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LICENSED VOLUNTARY SERVICE PROVIDER (MEDICAL) APPLICATION

Thank you for your interest in volunteering with the Coachella Valley Volunteers in Medicine Healthcare Center!

Our mission is to provide no-charge, primary health care services to medically underserved people residing in the Coachella Valley.
We do this through the provision of primary medical care, though certain medical specialty services are also provided.

IMPORTANT INFORMATION - CLICK TO READ

Please consider these requirements carefully before deciding to become a Volunteer.

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 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. 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.
Click ⊖ in upper right-hand corner to CLOSE this information.

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- Step 1 of 9

VOLUNTARY SERVICE PROVIDER (MEDICAL) APPLICATION

Is there a particular program you are interested in? Check all that apply. *

Direct Patient Care
Street Medicine | Homeless Medical Outreach
Residency Program | Preceptor
Health Education | Wellness Programs
Case Management Services
Clinical Lab | Medical Record Review | Audits

Are you bilingual Spanish? *

Yes
A little
Not at all

Is this a New Application? *

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SECTION 1: IDENTIFYING INFORMATION

Today's Date: *

Name *

First

Last

Office Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Birth Date: *

Phone (Primary Phone): *

Is this a MOBILE phone?

Email: *

Confirm Email

Primary Specialty: *

Secondary Specialty: *

Status: *

MD
DO
DMP
DDS
Dentist
PA
F/NP
RN
LVN
Pharmacist
RD (Dietician)
Dental Assistant
Dental Hygienist
Other:

Other status you currently hold/have held:

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SECTION 2: LICENSURE

CA License Number:

Enter your CA License Number. You must must be licensed to practice in the State of California.

Date Issued (CA License #): *

Expiration Date (CA License #): *

Upload a copy of your CA Professional License and DEA License (if applicable): *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Max file size: 32MB. Accepted file formats: .png, .jpg, .jpeg, .docx, .xls, .ppt, .pptx, .pdf

iPhone/iPad users: Your device may save images as .HEIC (.pages) files which must be converted to .pdf or .jpg format before upload. Use this free online conversion tool: cloudconvert.com/pages-to-pdf

Upload a copy of your Driver's License: *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Max file size: 32MB. Accepted file formats: .png, .jpg, .jpeg, .docx, .xls, .ppt, .pptx, .pdf

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SECTION 3: PROFESSIONAL EDUCATION

Institution: *

City: *

State: *

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SECTION 4: POST GRADUATE TRAINING: INTERNSHIP(S)

Type of Internship: *

Speciality (Internship): *

Date From (Internship): *

Date To (Internship): *

Hospital (Internship): *

Hospital Address (Internship): *

Address Line 1

City

State

Zip Code

Type of Residency: *

Date From (Residency): *

Date To (Residency): *

Institution (Residency): *

Institution Address (Residency): *

Address Line 1

City

State

Zip Code

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SECTION 5: BOARD CERTIFICATION

Are you Board Certified? *

Name of Board

Date Certified or Recertified *

Valid through: *

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SECTION 6: HEALTH STATUS

(1) Are you able to perform all the services required with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients? *

If the answer is NO, please provide an explanation and details in the field provided below.

(1) Health Status - Explanation/Details: *

If the answer is NO, please provide an explanation and details in the field provided below.

(2) Are you able to safely perform all the essential mental and physical functions related to the care of patients at the VIM Coachella Valley Clinic? *

(2) Health Status - Explanation/Details: *

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SECTION 7: 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?

(1) Clinical license in any jurisdiction? *

(2) Other professional registration or license? *

(3) DEA Certificate of registration or any applicable narcotic registration in any jurisdiction? *

(4) Membership on any hospital medical staff? *

(5) Clinical privileges, prerogatives/rights on any medical staff? *

(6) Board Certification? *

(7) Any other type of professional sanction? *

(8) Have you been subject to any disciplinary action in any health care organization, or is any such action pending? *

(9) Has any special monitoring requirements been imposed? *

(10) Have you resigned or taken a leave of absence in order to avoid possible revocation, suspension, or reduction of privileges at any hospital or institution? *

(11) Have there been, or are there any, misdemeanor or felony criminal convictions against you, or charges pending against you, or have you ever taken "deferred adjudication" on any matter? *

(12) <strong>Have you had any malpractice cases filed against you over the past five years?</strong> *

If you answered YES to Question 12, please complete Attachment "A" - Malpractice Claims Questionnaire, below.

ATTACHMENT "A": MALPRACTICE CLAIM / SUIT QUESTIONNAIRE

(1) The date the claim was made or suit was filed. If you do not recall the exact date, please state the year:

(2) Date of the alleged incident, which the subject of the claim or suit occurred:

(3) Name of claimant or plaintiff:

(4) Name of all defendants known to you:

(5) If the alleged incident occurred in a hospital, the name of the hospital:

(6) Set forth a brief statement of the facts of the alleged incident and if the matter is pending, it’s current status:

(7) If the matter has been concluded (whether by settlement, judgment or dismissal) state the method of conclusion and the date:

(8) If the matter has been settled, state the total amount of the settlement and any contribution made by you or your insurance carrier to the settlement:

(9) If the matter is concluded by judgment for the plaintiff, the amount of the total judgment and any amount against you if different:

(10) Also, state if the case was terminated by judgment in your favor or dismissal:

Your Legal Name

First

Middle

Last

Your Signature:

Clear Signature

Click in the box above the line, then use your cursor to draw your signature. Click the "x" to clear.

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AUTHORIZATION & SIGNATURE

REQUEST TO PROVIDE VOLUNTARY SERVICES

By my signature below, I acknowledge that I have the burden of producing information requested by Volunteers in Medicine Coachella Valley 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 VIM Coachella Valley 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.

Signature (Consent for Release of Information):

Clear Signature

Click in the box above the line, then use your cursor to draw your signature. Click the "x" to clear.

Legal Name (Consent for Release of Information): *

First

Middle

Last

Date

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INDIO:

82915 Avenue 48
Indio, CA 92201
760-342-4414

OPEN: Tuesday thru Friday
HOURS: 9:00am - 5:00pm

MAILING ADDRESS:
PO Box 10090, Indio, CA 92202

PALM SPRINGS:

Las Palmas Medical Center
555 E. Tachevah, Bldg 1W, Ste 204
Palm Springs CA 92262
760-342-4414

OPEN: Tuesday & Thursday
HOURS: 9:00am - 5:00pm

MAILING ADDRESS:
PO Box 10090, Indio, CA 92202

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