Please complete this application form if you are interested in becoming a Willing Helpers Medical Clinic volunteer. Once you complete the form, click the Continue button at the bottom.


Name and address


Demographic Information


Availability


Email Preferences

We like to keep volunteers informed of important news, schedules, and volunteer opportunities by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.



Skills, Training and Certifications


References

Please provide two personal or professional references



CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT

CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT

I acknowledge that in connection with my duties as a volunteer for WILLING HELPERS MEDICAL CLINIC, I may gain access to the demographic information and personal health information (as defined herein), of patients being serviced through the clinic, which is required by law to be kept confidential. For and in consideration of my participation in the clinic, I agree as follows:

1) Demographic Information refers to information that identifies an individual (name, address, telephone number, etc.)

2) Personal Health Information relates to past, present, or future physical and/or mental health conditions or any other information disclosed by a patient or discussed with a patient regarding the provision of clinical services provided through the clinic.

I understand that the clinic’s leadership has the expectation that I will hold in confidence and will not disclose, directly or indirectly, the personal information or any portion therefore communicated, discussed, delivered or made available by any patient.

I acknowledge that my obligation under this agreement remains in effect indefinitely.

I will take reasonable precautions to ensure that the confidentiality of patients’ personal information is maintained and will follow all clinic procedures in that regard.

The clinic’s policy is to safeguard access to personal information by taking reasonable steps to keep the information secure. I will not discuss personal information in public places or outside the clinic.

As a representative of the clinic, I acknowledge that I may only disclose personal information to volunteers or authorized advisors and consultants of the clinic with a specific need to know such information in order to serve the patient.

I also understand that the Health Information Privacy and Portability Act (HIPPA) set forth by the Department of Health and Human Services requires that all clinic personal maintain the privacy of all patient health information obtained in complete confidence. The HIPPA law passed in 1996 allows every patient the protection of privacy with regard to their health information.


BY CLICKING CONTINUE, I ACKNOWLEDGE THAT I HAVE READ AND AGREE TO THE ABOVE CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT: