Form PH3595 "Application for Registration to Provide Volunteer Health Care Services" - Tennessee

What Is Form PH3595?

This is a legal form that was released by the Tennessee Department of Health - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2007;
  • The latest edition provided by the Tennessee Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PH3595 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Health.

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Download Form PH3595 "Application for Registration to Provide Volunteer Health Care Services" - Tennessee

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1606 - $50.00
STATE OF TENNESSEE
DEPARTMENT OF HEALTH
HEALTH RELATED BOARDS
665 MAINSTREAM DRIVE
NASHVILLE, TENNESSEE 37243
(800) 778-4123, ext. 5324384
www.tennessee.gov
APPLICATION FOR REGISTRATION TO PROVIDE VOLUNTEER HEALTH CARE SERVICES
Use of this application requires the sponsoring organization to file a quarterly voluntary services
report with the department during the current quarter that lists all licensed health care providers
who provided voluntary health care services during the preceding quarter. The sponsoring
organization shall maintain additional information, including the date, place and type of services
provided, on file for five (5) years following the date of service. The report is to be forwarded to:
Department of Health, Board of Medical Examiners, Volunteer Health Services Coordinator, 665
Mainstream Drive, Nashville, TN 37243.
Please submit the completed application along with a check or money order in the amount of fifty
dollars ($50.00) payable to the Tennessee Department of Health to the following address:
Tennessee Department of Health, Board of Medical Examiners
Attention: Volunteer Health Services Coordinator
665 Mainstream Drive
Nashville, Tennessee 37243
Name of Sponsoring organization:
Name of officials responsible for the operation of the sponsoring organization:
PH 3595
Application – Page 1 of 3 Pages
RDA 1786
(Rev. 9/2007)
1606 - $50.00
STATE OF TENNESSEE
DEPARTMENT OF HEALTH
HEALTH RELATED BOARDS
665 MAINSTREAM DRIVE
NASHVILLE, TENNESSEE 37243
(800) 778-4123, ext. 5324384
www.tennessee.gov
APPLICATION FOR REGISTRATION TO PROVIDE VOLUNTEER HEALTH CARE SERVICES
Use of this application requires the sponsoring organization to file a quarterly voluntary services
report with the department during the current quarter that lists all licensed health care providers
who provided voluntary health care services during the preceding quarter. The sponsoring
organization shall maintain additional information, including the date, place and type of services
provided, on file for five (5) years following the date of service. The report is to be forwarded to:
Department of Health, Board of Medical Examiners, Volunteer Health Services Coordinator, 665
Mainstream Drive, Nashville, TN 37243.
Please submit the completed application along with a check or money order in the amount of fifty
dollars ($50.00) payable to the Tennessee Department of Health to the following address:
Tennessee Department of Health, Board of Medical Examiners
Attention: Volunteer Health Services Coordinator
665 Mainstream Drive
Nashville, Tennessee 37243
Name of Sponsoring organization:
Name of officials responsible for the operation of the sponsoring organization:
PH 3595
Application – Page 1 of 3 Pages
RDA 1786
(Rev. 9/2007)
Address of the sponsoring organization’s principal office:
Street
City
County
State
Zip Code
Telephone
Address of official(s) responsible for the operation of the sponsoring organization if different
from above: (Please attach additional sheets if necessary in order to provide this information).
Street
City
County
State
Zip Code
Telephone
Brief description of volunteer services to be provided:
(Please attach additional sheets if
necessary in order to provide this information):
Signature of Authorized Officer
Date
PH 3595
Application – Page 2 of 3 Pages
RDA 1786
(Rev. 9/2007)
CERTIFICATION
I, the undersigned, as the authorized officer of the
(
Name of Volunteer Health Services Organization)
hereby certify compliance by this organization with each of the following:
1. That there will be no charges or any kind to patients or to any third party on behalf of the
patients for any services provided to them by health care providers under the auspices of this
organization.
2. That all health care providers who are, or will be rendering services under the auspices of this
organization are:
a. licensed/certified in any state, territory, district or possession of the United States, as
evidenced by copies of current licenses/certificates on file with this organization; or
b. lawfully practicing pursuant to an exception/exemption from licensure/certification in any
state, territory, district or possession of the United States and does not now and will not in the
future regularly provide services under the Volunteer Health Care Services Act in Tennessee
pursuant to that exception. “Regularly” means practice of more than sixty days within a
ninety day period; and
c. practicing with licenses/certifications that are not suspended or revoked pursuant to
disciplinary proceedings in any jurisdiction, as evidenced by a copy of the health care
provider’s current license or certificate, or in the event that the health care provider is
currently licensed in the state of Tennessee, a copy of the health care provider’s license
verification obtained from a state-sponsored website; and
d. aware that any practice beyond the scope of an individual provider’s profession will disqualify
such provider from the protection of the “Volunteer Health Care Services Act” and subject
such provider to possible civil and criminal liability; and
e. aware that the intent of the “Volunteer Health Care Services Act” is to make their services
available to Tennesseans who may otherwise not be able to obtain such services and not for
the personal or professional gain of the provider and not to establish or promote the private
practice of any providers in Tennessee.
3. All services provided under the auspices of this organization shall at all times be provided in
compliance with all provisions of the “Volunteer Health Care Services Act.”
Signature of Authorized Officer
Date
Please Print Name of Authorized Officer
Title of Authorized Officer
Sworn and subscribed before me, this the
day of
,
Notary Public
SEAL
My Commission Expires:
.
PH 3595
Application – Page 3 of 3 Pages
RDA 1786
(Rev. 9/2007)
Page of 3