Thank you for volunteering with Remote Area Medical (RAM) as a volunteer telehealth provider.  Please note that at this time we are only accepting volunteer providers with valid NPI numbers.

This brief survey will collect the minimum information needed to create your profile on the CareClix platform.

Please make sure you are already registered as a RAM volunteer before completing this survey:

https://volunteer.ramusa.org/

You will also be asked for a profile photo and your current CV (preferably PDF).  Having these items readily available before you begin the survey will speed up the process.

After you complete the survey, a RAM Telehealth Admin will contact you about your desired volunteering schedule.

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* 1. Please enter contact info including email and phone you will use for RAM telehealth activity:

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* 2. Please provide your date of birth:

Date

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* 3. Preferred Title:

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* 4. What is your National Provider Identifier (NPI) number?

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* 5. Where did you complete your residency?

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* 6. Please select at least one and no more than three specialties to focus your telehealth service on:

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* 7. Please provide your primary medical license number, state of issue and expiration date (MM/DD/YYYY):

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* 8. If you are licensed in additional states, please provide medical license number, state of issue and expiration date (MM/DD/YYYY) for each:

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* 9. Please select your medical degree:

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* 10. Please select additional languages you are fluent enough in to practice telemedicine (English fluency is assumed unless you tell us otherwise):

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* 11. Please upload an appropriate profile photo - this is the first image of you that patients will see.

PNG, JPG, JPEG, GIF file types only.
Choose File

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* 12. Please upload your current CV (PDF only, please):

PDF file types only.
Choose File
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