Volunteer Form Volunteer Profile Name* First Middle Last Suffix Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Work PhoneEmail* Best time to call Employer/School Occupation/Previous Occupation In Case of Emergency Contact Relationship Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Emergency Contact PhoneTimes Available to VolunteerPlease check all that apply Monday Morning 9:00 AM - 12:30 PM Monday Afternoon 12:30 PM - 4:30 PM Monday Evening 4:00 PM - 8:00 PM Tuesday Morning 9:00 AM - 12:30 PM Tuesday Afternoon 12:30 PM - 4:30 PM Tuesday Evening 4:00 PM - 8:00 PM Wednesday Morning 9:00 AM - 12:30 PM Wednesday Afternoon 12:30 PM - 4:30 PM Wednesday Evening 4:00 PM - 8:00 PM Thursday Morning 9:00 AM - 12:30 PM Thursday Afternoon 12:30 PM - 4:30 PM Thursday Evening 4:00 PM - 8:00 PM Friday Morning 9:00 AM - 12:30 PM Friday Afternoon 12:30 PM - 4:30 PM Friday Evening 4:00 PM - 8:00 PM Areas of Special InterestPlease check all that apply Nursing Physician Pharmacist Dentist General Office (typing, filing, computer) Medical Referrals (Specialist appts.) Computer Operator Dinners (Provide meals for volunteers on clinic evenings) Recruiting other volunteers Patient Registration Pharmacy Asst. Dental Assistant Interview Patients/Screening Driver Building Repair and Maintenance Other Special Interest? Nursing License Number (if applicable) Physician License Number (if applicable) Pharmacist License Number (if applicable) Dentist License Number (if applicable) Dental Hygienist License Number (if applicable) Experience: Please indicate any previous work experienceList any previous experience in volunteer organizationsConsent* I agree to the Confidentiality AgreementConfidentiality Agreement Patient confidentiality Because of the nature of the Clinic’s work, it is imperative that information pertaining to patients is kept confidential. All applicable Health Insurance Portability and Accountability Act (HIPAA) and other legal standards and requirements will be complied with. This policy applies to volunteers as well as board and staff members of the Northern Neck Free Health Clinic. ● Under no circumstances are patients to be discussed outside the Clinic. Within the Clinic, cases should be discussed only with those directly involved. ● Joint conferences to discuss patients must be held in private and on a “need to know” basis. ● All information about patients, their illnesses or their personal lives must be kept in strict confidence. ● Access to patient records is restricted only to those who have a specific reason, in accordance with applicable law, to read the charts. ● Conversations with patients at the front desk, nurses’ station, lab, exam room and elsewhere must be held in a way that protects the patient’s privacy and confidentiality. When talking with a patient on any matter, it should be done in a way that other patients cannot overhear. ● Case histories, confidential papers and appointment books should not be kept in plain view. ● Do not give advice to patients on personal matters, even if they ask for it, and do not reveal patient information even to the patient’s family members. ● If patients ask about their own cases, refer them to a medical provider. ● Since medical information by a provider is confidential, no patient information will be provided to outside agencies except with the patient’s written consent or as permitted by applicable law.