Please fill in the information necessary to complete this application and then print this page. Please print or type the information to complete any attachments. Please sign where indicated and return to the address found at the bottom of this application. After your application has been recieved and approved, you will receive a contract package by email or U.S. Postal Service. To expedite this process email delivery of the contract package is preferred.

* Provider Name:

* Provider's Office or Home Address Information Only: If you do not want your contract package sent to this email or address, please enter alternate information below.

* By completing this section, you have elected to have the contract package sent to a different address than above. Please enter the alternate address and/or alternate email information below.

* Please Provide the License or Certification Number(s)and Date of Expiration.If you have more than on number to enter, separate entries with a semi-colon(;).

* I authorize the Oklahoma agency that issued my professional license or other authorization to provide health care services in Oklahoma to inform the contracting agency**, upon its inquiry, of the status of my license or authorization, including whether my license is in good standing, for the purpose of processing this application.

* Please identify your professional malpractice insurance carrier for the last five years:

If yes, please provide your claims history for any claim(s) brought against you within the last five years by attaching the claims information to this application. Minimally, the claims history must include the contact information of the reporting entity, the number of claims, a brief description of each claim, the type of heatlh care services being provided that precipitated each claim, and the money that was paid, or is being paid, per claim, if any.

* I authorize my professional malpractice insurance carrier to inform the contracting agency or the Risk Management Division of the Department of Central Services, upon its inquiry, regarding any claims history for the last five years for the purpose of processing this application.

* Please indicate the Community Health Centers you are associated with. You may enter up to five clinics.

* Please estimate how many hours per month you may participate as a charitable health provider. (Your estimate will help control the costs associated with the State insuring you, as a state emplyee, for purposes of the free services you may provide pursuant to the Volunteer Health Care Provider Program.)

* I hereby certify that the information provided in this application, including any attachments, is true and accurate to the best of my knowledge.

* Only natural or individual persons are eligible to contract with the Oklahoma State Department of Health or a city-county health department as a Community Health Center provider pursuant to OAC 310:2-27-2.
**"'Contracting agency' means either the Oklahoma State Department of Health or a city-county health department." OAC 310:2-27-2.

Please go to next page AFTER printing.

Please go to next page AFTER printing.
Oklahoma State Department of Health
Community Development Service: Rm. 511
ATTN: Volunteer Health Care Provider Program
1000 N.E. 10th Street
Oklahoma City, OK 73117