Health Unit on Davison Avenue (HUDA Clinic) LICENSED Volunteer Health Care Provider Form

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This form is for the listed Licensed Medical professionals only. (MD, DO, NP, PA, DDS, DMD, RDH, DPT, PharmD, RN, LPN, DPM, OD, MSW, LMSW, LLC, LPC, RD, CHES) You must hold an active Michigan License in order to be considered.

All other allied health professionals, please email our Clinic Manager, Shima Nagi with the subject "HUDA Clinic professional student volunteer inquiry" to Shima@Hudaclinic.org

Without the generosity of volunteerism from healthcare professionals, HUDA would not be where it is today. HUDA offers a unique experience in providing quality healthcare to under-served communities. If you are a licensed healthcare professional/provider, we hope you can help us continue our mission to "improve the lives of those in need through comprehensive health care, education, and resources."

Applications are reviewed on the first Wednesday of each month, providing it does not fall on a recognized holiday.

**Please know that the HRSA EHB FTCA is currently undergoing system upgrades to conform to the Paper Reduction Act and we are currently unable to add new providers to our Federal Tort policy. However, we do ask that you still complete the form so we are able to submit your application once the system is available to accept supplemental applications.

Your consideration will be based upon the findings of an initial background check.

Email *

Legal Name (name under which you hold your professional license), and credentials *

Specialty

Cell phone number *

Complete home address *

Current employer

If retired, please indicate retired

Time with current employer (if retired please indicate time with previous employer) *

University attended, Degree earned, graduation year. (undergraduate information for doctoral and masters applicants is not necessary)

Please include any fellowships here as well

Has your license ever been suspended, subject to disciplinary action or medical board review? *

Yes

If you answered Yes, please explain.

In addition to English, do you speak any of the following languages?

Spanish

Bangla

Arabic

Urdu

French

Farsi

American Sign Language

Other:

HUDA Clinic operates Tues, Thurs and Saturday. Please select your preferred volunteer availabilities below *

Tuesday: 9am - 3pm (On site)

Thursday: 9am - 3pm (On site)

Saturday: 9am - 3pm (On site)

I am available for consultations as needed

I am willing to see HUDA patients at my place of practice pro bono

I am willing to see HUDA patients at my place of practice for a reduced fee

I am available to provide telemedicine appointments for HUDA patients

Other:

Required

Thank you for your interest in volunteering with The Health Unit on Davison Avenue (The HUDA Clinic).

Please be on the lookout for an email from our Executive Director regarding next steps.

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A copy of your responses will be emailed to the address you provided.

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