Please complete this application if you are interested in becoming a Mission of Mercy Texas volunteer. When you complete the form, click the submit button at the bottom. We'll process your application quickly, invite you for a tour, complete a background security check, and then add you to the volunteer schedule.

Mission of Mercy Texas Overview

Please watch this short video introduction to Mission of Mercy Texas, and then return to complete your volunteer application: https://youtu.be/glIQ5Y26M64

Contact Information

First name:

Last name:

Middle name:

Title:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

* OK to call me here

Demographics

The following is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Gender:

Education:

Ethnicity:

Military Veteran:

Assignment Preference

Please let us know how you would like to serve.

Physicians, Registered Nurses, Nurse Practitioners, LVNs, EMTs, etc. – Provide direct patient care in a compassionate manor and representing our mission of restoring dignity, Healing through Love and providing free medical care to people who are uninsured.

Data Entry Assistant – Enter vital information into patient and volunteer records. Accuracy and attention to detail are the priorities, not speed. Training is available.

Registration Assistant – File patient records, checking patients in and out of the clinic, scheduling appointments. Computer skills a must, bilingual a plus. Training is available.

Office Assistant – Assisting with our bulk mailouts by stuffing, sealing and labeling envelopes for our direct mail, event postcards and invitations.

Volunteer Management Assistant – Help us serve and support our volunteers better.

Availability

Please indicate the days and times you are usually available to volunteer.

Emergency Contact

In the event of an emergency whom should we notify?

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Relationship:

EMail

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.

Email address:

What kinds of email would you like to receive?

Electronic newsletters

Recruitment appeals

Checklist reminders

Volunteer Information Center

We provide an online "Volunteer Information Center" where volunteers may check their schedules, update their information, and receive messages. Please select the password you would like to use to access the online Volunteer Information Center.

Please enter a password that:

Is between 6 and 30 characters long

Password:

Confirm password:

Employer Information

Please list your current or most recent employer, if applicable.

Employer name:

Street 1:

Street 2:

City:

State:

Zip:

Work phone:

HIPAA EMPLOYEE/VOLUNTEER CONFIDENTIALITY STATEMENT

Please review the HIPAA compliance section below. Your submission of this form signifies agreement to Mission of Mercy's HIPAA policies.

The policies of Mission of Mercy on the confidentiality of our patients’ health care information whether in written, unwritten, or electronic form. I understand that this information belongs to the patient and I am only the caretaker and must guard the information appropriately. This includes, but is not limited to, keeping patient health care information secure, private and out of public view, not discussing patient-specific issues and information in public areas, and protecting computer data by logging off work stations when not in use. I acknowledge that I have been trained on our legal obligations to protect the privacy of individually identifiable health information that we create, receive, or maintain as a health care provider. I pledge to abide by HIPAA’s Privacy Rules and by any state laws that provide greater protection or rights to patients.

I hereby agree and pledge that I will access only the information that is necessary for me to perform my responsibilities. I agree not to use, disclose or communicate any patient information in any manner whatsoever other than the minimum necessary for the provision of our services. I understand that all patient health care information will be released only to those who have a need to know and have signed a confidentiality agreement, to Business Associates with signed contracts and/or to individuals or organizations with signed authorizations for release. If I have any doubts, prior to releasing any information, I will discuss my concerns with our Privacy Officer.

I also understand that unauthorized use or disclosure of protected health care information may result in disciplinary actions up to and including termination of my employment.

I understand that my obligation, as outlined above, will continue after my employment or association with the practice/facility ends and that should I violate patient confidentiality appropriate sanctions will be taken.

HIPAA EMPLOYEE/VOLUNTEER TRAINING ACKNOWLEDGMENT

Watch this HIPAA Training Video - "https://www.youtube.com/watch?v=s9znUYvVO4A"

I have had the opportunity to view the HIPAA training video and have read and understand the HIPAA Privacy Training Guidelines of Mission of Mercy on the confidentiality of our patients’ health care information whether in written, unwritten, or electronic form. I acknowledge that I have been trained on Mission of Mercy’s HIPAA Privacy Policies and Procedures. I understand that, as a condition of my employment/volunteer service, I will follow the privacy guidelines of this practice.

My signature below attests to the fact that I have completed training, understand and agree to abide by the terms of this agreement.

I Agree

Hold Harmless Agreement -

As a volunteer staff member of Mission of Mercy, Inc., I am fully aware of the potential risks of illness, injury, and/or infection involved in the scope of medical services that will be provided by me and others involved with Mission of Mercy. I also acknowledge that the standard and prescribed measures to minimize these risks are being followed by Mission of Mercy.

I shall be solely responsible for and shall indemnify and save harmless Mission of Mercy, Inc., its Board of Directors, administration and staff, from and against all liability, loss, cost, detriment, damages and expenses, including medical and financial responsibility, for any illness, injury and/or infection incurred by me during or after my time as a volunteer staff member.

Consent to Photograph -

As a volunteer/staff member of Mission of Mercy, Inc., acknowledge that Mission of Mercy publishes newsletters, websites, etc. that promote the charitable work of Mission of Mercy. I hereby give my consent for Mission of Mercy, its Board of Directors, administrators and staff to use any photograph or images of me in any editorial or promotional material.

I understand and agree that submitting this application form does not automatically register me as a Mission of Mercy volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering.

By submitting this form, I attest that the information I have provided on the form is true and accurate.

_________________________________________________

I Agree