* Please enter clinic information below:

* Contact Person:

* Contact Person's Title:

* Medical Director or Supervisor:

* Enter time when clinic OPENS for each day of operation:

Sunday:
:
Monday:
:
Tuesday:
:
Wednesday:
:
Thursday:
:
Friday:
:
Saturday:
:

* Enter time when clinic CLOSES for each day of operation:

Sunday:
:
Monday:
:
Tuesday:
:
Wednesday:
:
Thursday:
:
Friday:
:
Saturday:
:

* Providers

* Other Licensed or Certified Providers: Please list type and number below

* Specialist Providers: Please list name, specialty, and location for each provider.

Provider Application Information:
Applications for your providers may be obtained online from the following site, http://www.ok.gov/health/Community_Health/Community_Development_Service/Primary_Care_&_Rural_Health_Development/index.html.

Please have each provider seeking participation as a Charitable Health Care Provider fill out an application on-line, print, sign and return the application to the address listed below. If your providers refer to or will refer to a specialist physician in a private practice setting, please list above, each specialist physician's name and location. The Office of Primary Care will contact the specialist physician for enrollment in the program.

Mail completed Provider Applications to:
Oklahoma State Department of Health
Community Development Service: Rm. 508.2
ATTN: Volunteer Health Care Provider Program
1000 N.E. 10th Street
Oklahoma City, OK 73117

T