Oklahoma Volunteer Charitable Health Provider Program

Oklahoma Volunteer Charitable Health Provider Program

Oklahoma Volunteer Charitable Health Provider Application

Thank you for your interest in the OVCHPP and for volunteering your time and expertise to charitable/free clinics across the state. In order to receive an OVCHPP Contract for 2023-2024, please complete the following steps and program requirements:

Please note, all volunteers for 2023-2024 must complete a new OVCHPP contract packet.

STEP 1: Complete the OVCHPP Contract Packet

Complete ALL information required in Contracted Packet. This Packet includes the 1) Healthcare Provider Application ; 2) Charitable Healthcare Provider Contract; 3) OSDH Certification of Independent Contractor Status; and 4) Clinic Acknowledgement to Maintain Patient records

*Proof of licensure may be requested at any point during this program.

STEP 2: Submit required documents by uploading into the OVCHPP Smartsheet form and filling out the required fields (you are here).

If you have not already, download the contract packet and fill it out. You may print and complete the form to upload or you may complete the packet as an electronic document. It includes...

Healthcare Provider Application
Charitable Healthcare Provider Contract
OSDH Certification of Independent Contractor Status
Clinic Acknowledgement to Maintain Patient Records

Fill out the information electronically, in this Smartsheet Form.

Attach your Completed Contract Packet at the end of this Form.

Volunteer First Name*

Volunteer_Middle_Initital*

Volunteer Last Name*

Volunteer Email*

At which you can best be contacted

Volunteer's County of Residence*

What is your Provider Type / Scope of Service?*

Select or enter value

Name of the Clinic*

City where the Clinic is Located*

Approximate Number of Hours Per Month You'll be Volunteering*

Clinic Contact*

Full Name of a Regular Clinic Contact

Clinic Contact Email*

Email of a Regular Clinic Contact Email

Name of Free Clinic Supervisor or Medical Director*

E-Mail of Free Clinic Supervisor or Medical Director*

File Upload

For expedited processing, please email completed application in PDF to Lisa.Sorrells@health.ok.gov

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