Please only complete this form if you are a licensed medical professional and interested in volunteering at Church Health. If you are not licensed, please complete the appropriate volunteer form for other areas. It is the responsibility of the health care volunteer to maintain active licensure and malpractice insurance. If the provider does not carry his/her own malpractice insurance, and is retired from practice other than at Church Health, he/she can request to be carried on our group Church Health malpractice policy.

Once you complete the form, click the continue button at the bottom of the page.

Upon completion of the application, please email any malpractice insurance information and your DEA number to the Volunteer Coordinator.

* indicates a required field.

Name and Address

First name:

Last name:

Title:

Street 1:

Street 2:

City:

State:

* Zip: *

Primary phone:

Alternate phone:

Email address:

Additional Information

Date of birth:

Medical Title:

Gender:

Specialty:

Race:

Employer:

Place of Worship:

License Number:

NPI Number:

License Expiration Date:

Please indicate if you have:

DEA Number

Malpractice Insurance

Vaccination Info

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring MMR and/or hepatitis B virus (HBV) infection. I have been informed of the risks and benefits of the Hepatitis B vaccine through a video presentation and/or through the brochures made available to me. My questions have been answered to my satisfaction. I further understand that MMR and/or Hepatitis B vaccine does not provide immunity from other forms of Hepatitis or other viruses. I have been given the opportunity to be vaccinated with the MMR vaccine and Hepatitis B vaccine, at no charge to myself and I understand the hepatitis vaccination is not recommended for pregnant women, nursing mothers, or those with a yeast allergy or current infection.

Church Health has a strict policy regarding the influenza vaccine to protect our community, patients, and staff. All clinic volunteers and staff are required to receive a flu vaccine which is available at Church Health. Clinic employees who decline vaccination must wear a mask between December 1 and March 31 when on Church Health property or working off-campus in an official Church Health function. Employees who are allergic to eggs or have a history of Guillain Barre syndrome may decline the vaccine; however, they must present a medical certification from their personal physician of their allergy or past reaction.

* Hepatitis B/MMR:

I decline the HBV/MMR vaccines

I have received the HBV/MMR vaccines

* Flu:

I am aware of the CH flu vaccine policy

* COVID-19 Vaccine:

I am fully vaccinated against COVID-19

I am NOT vaccinated against COVID-19

HIPAA and Patient Confidentiality

As a volunteer member of the workforce at Church Health, I understand the following in regards to HIPAA and patient confidentiality:

• Church Health has an ethical and legal responsibility to ensure the confidentiality of patient information. As a volunteer member of Church Health's workforce, I also have this responsibility.

• As a condition of my service, I agree to abide by all policies and procedures related to the privacy and security of all patients' protected health information (PHI).

• I will access, use and/or disclose only the PHI that is required for the performance of my job duties. If I have a question about whether or not I should access certain information, I will immediately check with the Privacy Officer or designee.

• Any personal access codes, user IDs, and passwords that I am assigned will be kept confidential at all times and are not to be shared with other workforce members.

• I will not remove any PHI from Church Health, paper or electronic form, without proper approval from the Privacy Officer or designee.

• I will not disclose information pertaining to patients to anyone that is not authorized to receive such information. This includes, but is not limited to, acquaintances, friends, and/or family members.

• I will not disclose PHI on any social media site, such as Facebook or Twitter, or any other internet outlet; including any discussion or description of patients (even if the patient is not specifically identified).

• I will not transmit PHI on any mobile device without using a secure messaging application approved by Church Health. This includes texting PHI to physicians, other workforce members and/or patients. I understand that texting PHI using the regular text messaging application on my phone can result in a HIPAA violation.

• I will not email PHI using a personal email account or any email account not approved by Church Health. If my job requires the use of email, I will follow the specific guidelines established for email by Church Health to use CHSecure in subject line of all email that includes PHI.

• I will not discuss information pertaining to patients with other workforce members including volunteers, unless I have a valid patient care related reason to do so.

• I will not make any unauthorized copies, modifications or deletion of PHI. This includes, but is not limited to, transferring PHI from Church Health's computer system to an unauthorized location, such as a personal computer, USB drive or personal email.

• Upon termination of my volunteer service with Church Health, I will immediately return all property belonging to Church Health. This would include, but is not limited to, keys to the facility, ID badges, documents, electronic files, computer equipment and/or mobile devices.

• I agree that my obligation to maintain confidentiality of PHI will continue after serving as a volunteer at CHURCH HEALTH. I understand that knowingly using or disclosing PHI in violation of the HIPAA Privacy Rule is a criminal offense and I may personally face fines and/or time in jail.

• Any violation of this Agreement may result in disciplinary action, up to and including termination of my volunteer service with Church Health.

* HIPAA:

I agree

Confidentiality & Participation Agreements

We are privileged to have a community of physicians dedicated to helping us serve our community of need with compassion, quality, and professionalism. We welcome you to the Church Health family and would like to share some practices and principles that help guide all of us here at the Church Health as we work together.

Our Mission

Church Health seeks to reclaim the Church’s biblical commitment to care for our bodies and our spirits.

Our Values

I. We are welcoming to people of all beliefs and respectful of their individual needs.

II. We are compassionate, nurturing the health, well-being, and dignity of each other and those we serve.

III. We are collaborative, seeking and sharing best practices, and respecting the mutual contributions we make in fulfilling our mission.

IV. We are innovative, challenging ourselves and our partners to improve the way we work and serve.

V. We are passionate in the pursuit of our mission.

VI. We serve all equally, with integrity and openness, breaking down barriers that build injustice.

We support and cultivate:

* A culture of respect, kindness, compassion and excellence.

* A spirit of collaboration, teaching, learning, and sharing.

As a physician leader, you are expected to promote respectful communication with our staff and with our patients. If you ever have a concern, please contact Dr. Susan Nelson, our Medical Director, at (901) 825-7981.

Unacceptable behaviors for ANY members of the Church Health family:

* Shouting, yelling, foul language, or discriminatory comments.

* Hostile, intimidating, condemning, or demeaning communications.

* Sexually inappropriate remarks or body language.

I agree that I render these health care services voluntarily, without compensation or the expectation or promise of compensation. This acknowledgement and agreement has been made before rendering any services.

I agree to report to the appropriate persons any incidents or injuries in which I am involved with during my volunteer service. I understand that my service as a volunteer is covered up to the limits specified by the center’s insurance program and I hereby waive any claim against the center except as specified herein.

I certify that the statements I have made in this application are true and accurate.

I Agree