Please complete this application form if you are interested in being a Volunteer Medical Provider (MD, DO, NP, PA, RN) or Pharmacist at CommunityHealth. Once you complete the form, click the Submit button at the bottom of the application.
CommunityHealth operates in compliance with the Illinois Good Samaritan Act. Per the state statute, with the exception of willful or wanton misconduct, all volunteer licensed medical professionals are exempt from medical liability.
All volunteer providers are screened through the Office of the Inspector General Exclusions Program and the Excluded Parties System List. Any volunteers for whom professional licensure is required will be screened through the Illinois Department of Professional Regulations. Any provider who will be prescribing medication will be screened through the National Provider Data Base.
***If you are not a licensed/certified provider, please sign up for a clinic volunteer info session on the volunteer page of our website. Do NOT fill out this form.***
Please tell us how you heard about CommunityHealth. What is your reason for volunteering? What do you hope to gain from this experience?
Are you applying already with the intention of serving as attending for one of our established student-run clinics, or as a provider with one of our established resident/fellow-based clinics? If so, which?
Please indicate what services and specialties you are willing to offer at CommunityHealth. Please also indicate at which location(s) you might be interested in serving, how often you are willing to volunteer (minimum 1, 4-hour shift per month), and what days/times are best (check all that may apply).
Please list any licenses applicable to this volunteer position.
Please list your current employer (if applicable).
Do you have privileges at any hospitals? If, yes, please list hospitals.
Do you speak Spanish or Polish fluently? Check only if you would be comfortable providing all services in the target language without use of an interpreter.
Are you currently, or have you ever been a registered CommunityHealth patient?
Please list any volunteer experience you have had in the past 5 years (include organization name, your position, how long you volunteered, and your reason for leaving).
CommunityHealth operates in compliance with the Illinois Good Samaritan Act. Per the state statute, with the exception of willful or wanton misconduct, all volunteer licensed medical professionals are exempt from medical liability. More information can be found at www.ilga.gov.
In addition, CommunityHealth carries a policy providing professional liability coverage for all volunteer providers, covering only your volunteer work at CommunityHealth. This baseline policy gives us all solid ground to stand on with confidence, and while this policy does cover everyone (limits of liability: $1,000,000 each claim, $3,000,000 aggregate limit), we continue to encourage additional coverage whenever possible.
We recommend exploring and/or maintaining an individual policy as well. Volunteer physicians may pursue an affordable (as low as $50/year) policy through the Illinois State Medical Insurance Exchange (ISMIE, www.ismie.com). All other medical professional volunteers can purchase additional malpractice insurance at discounted rates through the Healthcare Providers Service Organization (HPSO, www.hpso.com)
• I have medical malpractice insurance that will cover services rendered at CommunityHealth.
• I do not have medical malpractice insurance that will cover services rendered at CommunityHealth and will need to rely on the clinic's policy.
Please tell us who we should contact in case of an emergency. Finally, please list two professional references.