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 volunteers are screened through the Office of the Inspector General Exclusions Program and the Excluded Parties System List. Any volunteers for which professional licensure is required will be screened through the Illinois Department of Professional Regulations.


***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.***


Demographic Information


Volunteering at CommunityHealth

Please tell us how you heard about CommunityHealth. What is your reason for volunteering? What do you hope to gain from this experience?


Supervision

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?


Services + Commitment

Please indicate what services and specialties you are willing to offer at CommunityHealth. Please also indicate how often you willing to volunteer (minimum 1, 4-hour shift per month), and what days/times are best (check all that may apply).


License + Certification

Please list any licenses applicable to this volunteer position.


Employment

Please list your current employer (if applicable).


Hospital Privileges

Do you have privileges at any hospitals? If, yes, please list hospitals.


Languages

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.


CommunityHealth Patient Status

Are you currently, or have you ever been a registered CommunityHealth patient?


Volunteer Experience

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).


Liability Coverage

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)

Select One:

• 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.


References + Emergency Contact

Please tell us who we should contact in case of an emergency. Finally, please list two professional references.


Volunteer Expectations, Waiver, EMR User Agreement

The success of CommunityHealth depends on active participation from its volunteers, patients and staff, all working towards one common goal - quality healthcare for the uninsured. Since communication, cooperation and responsibility are key concepts to keep CommunityHealth running effectively and efficiently; clear expectations are needed. Below are essential expectations of any independent volunteer provider.

Volunteers are expected to:

" Provide proof of negative TB test each year
" Provide proof of any licenses and certifications as required
" Commit to at least one 4-hour shift per month for at least one year
" Notify the Manager of Volunteer Services AND Clinic Coordinator *at least 24 hours in advance* if you are going to be late for or entirely miss a scheduled shift
" Treat all patients, volunteers, and staff with dignity, respect and courtesy
" Maintain a positive attitude and relationship with all other volunteers, staff and patients
" Maintain confidentiality, whether it is with the patient, staff or other volunteers (what is said or done here remains here)
" Attend any required training sessions, as directed by CommunityHealth staff
" Understand and abide by all CommunityHealth policies, rules and regulations
" Understand that CommunityHealth has the right to refuse/remove any volunteer at any time as it deems fit

Volunteer Release and Waiver of Liability

This Release and Waiver of Liability (the “Release”) releases CommunityHealth, a nonprofit corporation organized and existing under the laws of the State of Illinois and each of its directors, officers, employees, and agents. The Volunteer desires to provide volunteer services for CommunityHealth and engage in activities related to serving as a volunteer.

Volunteer understands that the scope of Volunteer’s relationship with CommunityHealth is limited to a volunteer position and that no compensation is expected in return for services provided by Volunteer; that CommunityHealth will not provide any benefits traditionally associated with employment to Volunteer; and that Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness as a result of Volunteer’s services to CommunityHealth.

A. Waiver and Release: I, the Volunteer, release and forever discharge and hold harmless CommunityHealth and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services I provide to CommunityHealth. I understand and acknowledge that this Release discharges CommunityHealth from any liability or claim that may have against CommunityHealth with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to CommunityHealth or occurring while I am providing volunteer services.

B. Insurance: Further I understand that CommunityHealth does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of CommunityHealth beyond what may be offered freely by CommunityHealth in the event of injury or medical expenses incurred by me.

C. Medical Treatment: I hereby Release and forever discharge CommunityHealth from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a volunteer with CommunityHealth.

D. Assumption of Risk: I understand that the services I provide to CommunityHealth may include activities that may be hazardous to me, as indicated by clinical work involving inherently dangerous activities. As a volunteer, I hereby expressly assume risk of injury or harm from these activities and release CommunityHealth from all liability.

E. Other: As a volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Illinois and that this Release shall be governed by and interpreted in accordance with the laws of the State of Illinois. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

In checking "I Agree", I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily.

CommunityHealth EMR User Agreement

CommunityHealth is committed to protecting the privacy and security of individual identifiable health information and other protected health information of a confidential nature for the organization. Information pertaining to patients and other sensitive information must be held in strict confidence.

I hereby acknowledge that I have been given access to the electronic medical recorded (EMR) for CommunityHealth to view, document and/or print patient information using secured and unique user identification and password combination to Athena Health. My User ID will provide access to patients’ EMR and I understand that this is for use by me only. Any printed information will be in my possession only and used only in treating patients. I further acknowledge the following:

A. I understand that I will not attempt to access any medical records/information of patients for whom I am not involved in the care or treatment of. I also understand that I will not attempt to access any medical records/information that I am not authorized to.

B. I understand and agree that I must hold all medical information in confidence and not disseminate any of the accessed information for any purpose other than medical care and authorized purposes. I understand that any violation of the confidentiality of medical information may result in a violation of State and Federal law and may result in a claim for damages and /or punitive action. I agree to review this Agreement on an annual basis.

C. Any information obtained from the EMR to which you have access is confidential and must not be disclosed to others unless the patient or his/her authorized representative explicitly consents to such disclosure.

D. Specific state and federal requirements regarding protection of alcohol and drug abuse records, mental health records and HIV-related information prohibits you form making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or other information is not sufficient for this purpose.

E. I understand that my user password will need to be changed every 60 days.

F. I understand and agree not to share my user ID or password with anyone.

G. I will be responsible for acting in a prudent manner to maintain security of any remote access devices used to access patient information.

H. I understand that upon termination of my employment or volunteer services at CommunityHealth, my user ID will be immediately deactivated.

In checking "I Agree", I confirm that I have read and understand the Athena User Agreement in its entirety. I hereby agree to the obligations as outlined in the Agreement.