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Volunteer and Retired Providers Program Site Application

Thank you for your interest in participating in the Volunteer and Retired Providers (VRP) Program as an approved site. The following documentation is necessary to ensure your site meets all requirements of the law in order to be eligible for malpractice and license renewal support for your volunteers in Washington State.

Participation in the VRP Program requires affirmed compliance with state and federal civil rights protection against discrimination on the basis of race, color, national origin, age, disability, sex, creed, gender, gender expression or identity, sexual orientation, marital status, religion, honorably discharged veteran or military status, or the use of a service animal by a person with a disability. You must also affirm that participation in religious activity is not required for individuals to receive healthcare services from your organization.

By checking this box, I acknowledge that our organization complies with the above requirements and has a nondiscrimination policy that complies with state and federal civil rights protection.

Please check or Initial below

Initials

CONTACT INFORMATION

Site/Clinic Name

Site/Clinic Address (Address Available to Public)

City

State

ZIP Code

Do you offer mobile services?

YesNoOther

Other Mobile Services

Site/Clinic Phone Number (Phone Number Available to Public)

Site/Clinic Website

Site/Clinic Mission as stated on 990

Please upload the cover sheet of your 990

Name of Individual Completing this Form

First Name

Last Name

Title of Individual Completing this Form (E.g. Volunteer Coordinator, Executive Director, Etc.)

Email of Individual Completing this Form

Phone Number of Individual Completing this Form

Organization Profile

Is your site/clinic a one-time event/pop-up clinic/health fair?

YesNo Other

Other:

How is your site set up?

The site is a public entity or a private tax exempt corporation.The site is a for-profit corporation holding itself out to the public as having established hours on a regular basis for providing free health care services to members of the public, meaning that care is provided without compensation or expectation of compensation during these established hours.The site is a for-profit corporation maintaining and holding itself out to the public as providing healthcare services to Medicaid patients with a posted sliding fee schedule. Sites need to assure that patients below 100% of the Federal Poverty Level (FPL) pay a very nominal fee (or no fee) and that patients between 100-200% of the FPL are discounted.The site is a for-profit corporation participating (through a written agreement) in a community-based program to provide access to healthcare services for uninsured patients, to the extent that care is provided without compensation or expectation of compensation to individuals who have been referred for care through that community-based program, and the healthcare provider's participation in the community-based program is conditioned upon his/her agreement to provide health services without expectation of compensation.

Please upload appropriate documentation below.

Documentation may include current policies and procedures, a sample provider agreement, and must include a copy of the written agreement with the community-based program.

Organization Profile, Continued

Please describe how health care services are offered to low-income patients regardless of their ability to pay. A sliding fee scale is an example of consideration of a patient’s ability to pay.

How does the site/clinic assure continuity of care for patients? Please describe mechanisms in place at the site which assure continuity of care. Record systems are an example of mechanisms to assure continuity.

Please describe the site/clinic’s arrangements for after hours coverage either to provide care or refer patients.

Please describe the site/clinic’s referral system to assure the patient access to necessary care beyond the non-invasive care given by the volunteer provider.

I attest that any providers participating in this program will not receive monetary compensation for volunteer services provided.

By selecting this button, I confirm that volunteers using the VRP Program will not receive monetary compensation for any volunteer care provided.

Confirmation and Submission

Would you like to be included on our database of volunteer opportunities available to the public?

YesNo

The VRP Program surveys all affiliated VRP sites and VRP providers on an annual basis to track the value of this publicly-funded program. We ask that you complete a survey on behalf of your organization and assist us in reaching out to providers to ensure they too respond to the survey.

I understand that in participating in the VRP Program, I will be required to complete an annual survey.

By checking this box, I acknowledge that I understand the VRP survey requirement.

Is there anything else you would like us to know about your organization or application?

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