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Upon completion of this request and addendum, the Original contract as a Charitable Health Care Provider is incorporated by reference as if fully set forth herein. Failure to submit this renewal to OSDH shall result in expiration of the original contract as a charitable health care provider.
Please print legibly or type the information necessary to complete this application, including any attachments.
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Provider Information:
Prefix:
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Provider Name:
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Address Information:
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Please select the Oklahoma agency that issued your license or authorization to provide health care services that is relevant to your application to enter into a contract with a contracting agency to be a charitable health care provider:
Issuing Agency
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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(;).
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Please attach a summary of any professional discipline assessed against you as a health care provider in the last 12 months, including what the specific discipline was and the underlying basis for such discipline.
Professional Discipline
I hereby declare, by my signature below, that I request the renewal of my contract as a charitable health care provider for the next contract period of July 1, 2012 through June 30, 2013 unless contract is terminated by my written notice to OSDH. I authorize OSDH to contact the agency who issue my professional license or certification if deemed necessary by OSDH to determine its current status and standing.
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Please identify your professional malpractice insurance carrier for the past year:
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Have you had any professional malpractice claims brought against you within the last year?
Select One:
Professional Malpractice
If yes, please provide your claims history for any claim(s) brought against you within the last year 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 year for the purpose of processing this application.
If possible, please estimate how many hours per month or year you provided as a charitable health provider. (Your
estimate will help control the costs associated with the State insuring you, as a state employee, for purposes of the free services you may provide pursuant to the Volunteer Health Care Provider Program.)
Please select yes or no for the following which best describes your participation with a free clinic.
A. I am associated with a free clinic(s) only.
B. I will provide free specialty care to patients who are referred from a free clinic provider to my private practice setting and declare that no charges or expected payment is required from the patient, and further declare the patient will not be charged for my services.
For persons providing services on referral basis (Question B from above):
I hereby certify that the information provided in this form, including any attachments, is true and accurate to the best of my knowledge.
Please go to next page AFTER printing.
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Please return this application to:
Volunteer Health Care Provider Program
Oklahoma State Department of Health
Community Development Service, Rm 508.2
1000 N.E. 10th Street
Oklahoma City, OK 73117
For Questions or Comments Call:
(405) 271-8427
E-Mail: OKVCHP@health.ok.gov
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