Project Access San Diego Partner Commitment Form

Hello, Thank you for being interested in supporting our flagship program, Project Access San Diego. We are humbled to have caring health champions like you help the most vulnerable in San Diego County. Please complete our commitment form below and a staff member will follow up with you shortly.

Name of Volunteer or Organization

Name of Company/Practice if Different

Address of Company/Practice

City

State

Zip Code

Company/ Practice Phone Number

Company/ Practice Fax Number

Office Manager Contact Information

Or whoever is the best contact to work with at your practice.

Name

Email Address

Phone Number

Language Support

Does your practice require medical interpretation support for patients who are mainly Spanish speaking?

Answer below:

Select or enter value

Volunteer Physician Details

Physician's Email Address

Physician's Specialty

Physician's Hospital/Surgery Center Affiliations

Please Provide Physician's DEA Number and Expiration Date. This is needed for Prescription Assistance Programs)

DEA Number

DEA Expiration Date

Physician's California Medical Board License #

How many NEW patients a year are you willing to see.? Note you can increase or decrease the number of patients you wish to support at any time.

Number of NEW patients a year

Please tell us a bit about your areas of interest within your specialty. We try our best to send you referrals that meet your preferences.

Interests

How Did You Hear About Project Access?*

Select or enter value

Do You Know Any Colleagues Who May Want To Volunteer?

We are always looking for more health champions like you to support our cause. If you know of any like-minded colleagues, we would be happy to follow up. We also have a Physician Recruitment Committee that is made of physicians, hospital leaders, and more. We would be humbled to have your expertise on these efforts.

Please Answer Below

Select or enter value

Please print your name below to complete this form. By signing, you agree to support Project Access San Diego, a program that connects eligible, low-income uninsured San Diegans with specialists that provide pro-bono specialty care. A staff member will contact you within 72 hours to discuss the next steps and we thank you for your support!

Print Name Below

Send me a copy of my responses

Privacy Notice|Report Abuse