Volunteer Nurse Practitioner Application

Name: Clinic: Volunteer Nurse Practitioner Application AmeriCares Free Clinics, Inc. 88 Hamilton Avenue, Stamford, CT 06902 Phone: (203) 658-9500 ~ Fax: (203) 658-9612 Email: freeclinics@americares.org www.americaresfreeclinics.org Application Checklist Please complete the application and mail, fax or email to the above address along with the following documentation: 1. Copy of Connecticut license. 2. Copy of NP Certification 3. A letter of recommendation from your current/former employer or medical colleague attesting to skills as an independent adult practitioner for a period of two full years. 4. For NPs retired more than two years evidence of some continuing work in a related field. 5. Copy of DEA license (state and federal) if retired, optional. 6. Curriculum Vitae (optional). 1

Date: Personal Information Clinic: Name: Address: City: State: Zip: Birth date: (m/d/y) SS#: Phone-Home: Office: Cell: Email: Emergency Contact: Name/Phone Do you speak any other languages? Are you currently employed? If retired date of retirement: If currently employed: Employer: Title: Address: City: State: Zip: Preferred AFC Site: Bridgeport Danbury Norwalk Stamford Mobile Unit Availability: Please check days and times that you are available Sessions Monday Tuesday Wednesday Thursday Friday Saturday 9-12 am Closed 12-4 pm Closed 4-7 evening Closed How did you hear about our program? Please Check: Another volunteer Radio/ TV AFC website Volunteer website Newspaper/ other print AmeriCares staff or board Other Current Practice CT Medical/APRN License #: Date Licensed: Expiration Date: NPI #: Federal DEA # Are you licensed in any other states? Expiration Date: State: License # Expiration Date: Education NP Program: Name of School City: State: Year Graduated: Degree: Specialty Type: Number of CME credits last year? Past 2 years: 2

Please list the professional organizations in which you are a member: Please attach CV or answer the following: Where have you practiced your profession in the last eight (8) years? Include military or any public service and any gaps in practice. (Attach a separate sheet if needed.) City/State From (m/y) To (m/y) Please list the hospitals where you have privileges, their address and your status (attach a separate sheet if needed). Hospital City/State Status Please answer the following questions: ** 1. Have you ever been investigated, disciplined, censured, or reprimanded by a medical society, professional review board, or state licensing entity or board or had a complaint against you submitted to any such entities? Yes No 2. Have you ever had your membership in any professional society or association refused, suspended, revoked, or received any criticism or reprimand from any specialty society? Yes No 3. Have your hospital privileges ever been restricted, denied, suspended, revoked, or has any disciplinary action been taken against you? Yes No 4. Has your medical or DEA license ever been restricted, voluntarily surrendered, suspended or revoked? Yes No 5. Have you ever been charged with a felony or misdemeanor other than minor traffic offenses? Yes No 6. Do you have any personal health problems that might affect your ability to safely practice medicine? Yes No 7. Have you ever filed a long-term disability claim where the claimed disability impacted your ability to perform any aspect of your medical practice? Yes No 8. Are you currently or have you ever been treated for a psychiatric condition, alcoholism or substance abuse? Yes No **If you answered yes to any of the above questions, please explain in a separate letter. 3

Insurance and Claims History 1. List previous med. professional liability policies for the past 8 years: (Use separate sheet if needed) Company Policy Limit Policy Period Retro Date Premium Claims Made Occurrence 2. Has any insurer ever canceled, declined or reduced coverage (i.e., reduced limits, restricted coverage, surcharged rates, or refused renewal for this or any similar coverage)? Yes No If Yes, please provide details: 3. Have you ever submitted to a liability insurer or risk transfer instrument any claim or given notice of any fact, situation, transaction, event, act, error or omission for a malpractice claim, suit or incident, either directly or indirectly? Yes No 4. Other than claims or potential claims that have been previously reported, are you aware of any fact, circumstance, situation, transaction, event, act, error or omission which you know or reasonably should know may result in a claim that may fall within the scope of the proposed insurance? (For the purposes of this question, reasonably should know includes any act, error, omission or occurrence that alleged sexual, physical or emotional abuse or misconduct; or was the subject of any peer review; professional or specialty association, accreditation or licensing entity; local, state or federal investigation; JCAHO near miss investigation; sentinel event report or root cause analysis; incident report investigation; written notification, inquiry or demand by legal counsel or matter submitted to legal counsel; mandatory report on professional conduct; or similar investigation or review.) Yes No If Yes to either question 3 or 4, please describe each claim, suit, or incident regardless of its outcome, on the Malpractice Claims Information form(s) at the end of this Application, and attach a carrier claim report from the past ten (10) years including amounts paid and reserved. Any Malpractice Claims Information forms and carrier claim reports are part of this Application. Note: Without prejudice to any other rights and remedies of the underwriter, it is agreed that any claim, or related claim, arising out of any fact, circumstance, situation, transaction, event, act, error, or omission that is or should have been disclosed in response to Questions 3 or 4 is excluded from the proposed insurance. Confidential Information I understand and acknowledge that: 1. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and other confidential information relating to AmeriCares Free Clinics and its affiliates, including business, employment and medical information relating to our patients, members, employees and health care providers. 4

2. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information. 3. My obligation to safeguard patient confidentiality continues after I am no longer an AmeriCares Free Clinics volunteer. Insurance Volunteer Accident Insurance is provided and is a medical insurance policy which covers accidents involving volunteers at the clinic site. Volunteer Accident Insurance pays after the Volunteer s insurance pays. If the Volunteer has no insurance, the policy pays up to the limits of coverage. The Volunteer understands that, except as otherwise provided above AmeriCares Free Clinics does not carry or maintain health, medical, or disability insurance coverage for any Volunteer. Photographic Release Volunteer does hereby grant and convey unto AmeriCares Free Clinics and AmeriCares all right, title, and interest in any and all photographic images and video or audio recordings made by AmeriCares Free Clinics or AmeriCares during the Volunteer s Activities with AmeriCares or AmeriCares Free Clinics. In the event of any material untruth, misrepresentation or omission in connection with any particulars or statements in this application, any issued policy shall be void with respect to any insured who knew of such untruth, misrepresentation or omission or to whom such knowledge is imputed. I understand that AmeriCares Free Clinics will rely, in part, on the information I provide in this Volunteer Application in considering whether to qualify me as a volunteer. I understand that it is important that I provide complete and accurate information and certify that I have done so. I authorize the organization to contact anyone that it deems appropriate to verify the information I have provided or to further investigate my background, past performance and suitability as a volunteer for AmeriCares Free Clinics. I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. Applicant (please print) By (Signature) Date: Rev. 10/2016 5

Malpractice Claims Information (To be completed in response to questions 3 & 4 on page 4) 1. Name of patient/claimant: Sex: Age: 2. Allegation and date of incident: 3. Location: 4. Your relationship to the patient (attending physician; APRN, etc.): 5. Insurance carrier and policy number: Status Open- Reserve Amount $ Amount Closed Loss Amount $ Date: Settlement- Total Amount $ Your Portion: $ Judgment- Total Amount $ Your Portion: $ 6. Other defendants: 7. Condition and diagnosis at the time of the incident: 8. Description of medical treatment rendered: 9. Condition of patient subsequent to treatment: 10. To whom may we refer to obtain further information regarding this claim or lawsuit? Rev. 1/2016 6

Scope of Practice The mission of the AmeriCares Free Clinics is to provide free quality medical care to the uninsured and the underinsured using volunteer professional staff. The Clinic s intention is to help those who are making a sincere effort to help themselves and their families, but have no financial resources for medical care. The AmeriCares Free Clinics is an ambulatory care facility providing services for commonly occurring self-limiting acute illnesses, chronic conditions and certain preventative health/health maintenance needs of adults (and children in Norwalk). Potentially severe or emergent care situations will be referred to appropriate health care settings with the requisite facilities and equipment. Chronic conditions with the likelihood of severe or emergent complications will be referred to the appropriate facility for long term follow up. Definitions of services provided: (These definitions are to serve as an example and by no means imply a complete listing.) Self-limiting acute: Upper respiratory infections, urinary tract infection, flu, sore throats, rashes, generalized pain Chronic conditions: Diabetes, hypertension, hypothyroidism, asthma, seasonal allergies, osteoarthritis Prevention/health maintenance: School or work physicals (excluding motor vehicle and foster child care), TB testing, immunizations (for children in Norwalk). Procedures: EKGs, venipuncture, minor incision and drainage without sutures Specialty Clinics: as available Services provided in clinic: Initial assessment of all presenting conditions Follow up care after initial assessment, if within the Scope of Practice Appropriate referrals to other health care providers. For example: Any emergency care Call 911. Any unstable acute or chronic illness refer to a hospital emergency department. Any condition with the likelihood of severe or emergent complications Note: Any unstable chronic condition can be referred to an outside specialist for assessment and follow-up related to that condition while other basic health care is provided by AFC. For example: Mental health is referred, but other health needs are met at AFC. I have reviewed and agree to work within the above Scope of Practice. Signature Date Print Name 7 Rev: 10/2016

Volunteer Nurse Practitioner Job Description Summary: The NP will function as an independent practitioner within the scope of nurse practitioner practice as defined by the American Nurses Association and the laws of the State of Connecticut. Administrative supervisor: Clinic Director Medical Supervisor: Medical director Requirements: Current Connecticut advanced practice registered nurse license, with certification in an appropriate area of practice as a nurse practitioner. Minimum two years of recent full time experience caring for adults with chronic and episodic medical conditions. The same experience is required of the pediatric NP in that field. One letter of recommendation from health care provider familiar with candidate s recent clinical practice. Successful completion of Americares Free Clinic s Credentialing Process. Ability to work with diverse populations and age groups A passion to help the underserved Ability to work as an effective member of a dedicated team of volunteers and staff Sound understanding of and commitment to AFC mission and philosophy Responsibilities: 1. Perform professional medical services in the examination, diagnosis, care and treatment of physically ill patients, within the limits of experience and professional training. Provide appropriate patient instruction and/or consultation with family or significant other, as needed. 1. Collaborate with other health care providers and community health resources, and make appropriate patient and/or family referrals. 2. Identify patients outside of the NP s scope of practice and refer to the Clinic physician, or to a specialist, as appropriate. If no physician consultation is present, or if urgent attention is required, the patient will be sent to the hospital emergency room. 3. Review diagnostic testing reports and PAP applications as needed. 4. Note in the patient s chart any consultation with physician staff regarding the delivery of patient care, indicating the name of the physician consulted in the case. 5. Deliver patient care in accordance with the Americares Free Clinics Policies & Procedures, universal precautions and infection control principles. 6. Maintain patient confidentiality 7. Attend Medical Staff Meeting and periodic in-service activities whenever possible. Signature Date 3/2017

Americares Free Clinics Health Clearance Name Date of Birth Street Address Town Zip Position: Paid Employee Title Volunteer Title This section must be completed by a Physician, Physician Assistant or Advanced Practice Registered Nurse This medical clearance is an important requirement designed to protect the health, safety and welfare of the patients served in the Americares Free Clinics. 1. To the best of your knowledge, does this person have any medical or emotional illness or disorder that would currently pose a risk to patients, staff or volunteers of the free clinic or would interfere with their ability to complete their job? Yes No If yes please explain 2. To the best of your knowledge, is this person free of communicable disease? Yes No Comments 3. Required check for Tuberculosis upon employment. This can be completed by either Americares or employee/volunteer s physician. Tuberculosis Screening Form attached and must be signed by medical provider. 4. TDAP (every 10 years) and annual flu vaccine is recommended. Flu Vaccine Date: TDAP Date: 5. Hepatitis B vaccine series recommended for medical staff and volunteers. Vaccine Series completed Declination Comments 6. Medical Provider s Information Name Address Phone # / Signature of MD, APRN, PA Date APP-002 Rev. 7/7/17

Tuberculosis Screening Form for Staff and Volunteers This testing must be done within one month of joining the staff. We can do the skin test on-site or your private provider can do the skin test or order the blood test. Skin test results cannot be read by volunteer/employee. If you have never been tested for tuberculosis before: A Two Step Tb Skin Test (TST) is required, or QuantiFERON TB Gold In-Tube Blood Test Results Date If you have had a negative TST within the last year or two or more negative TSTs in the past: A single TST is required, or QuantiFERON TB Gold-In Tube Blood Test Results Date If you have had a positive TST in the past: No further testing is required Your provider will be asked to attest to one of the statements below: This individual has no evidence of active tuberculosis and is aware to report any symptoms that develop. This individual was treated appropriately for latent tuberculosis and is cleared to work in a health care facility. This individual has/had active tuberculosis and is being/has been treated with appropriate therapy and is cleared to work in a health care facility. Medical Provider Signature Date