Volunteer Form

SCMS HealthAccess

 

Physician Volunteer Form

 

                                           Date:__________

Name: __________________________________________________

Practice: ______________________________Specialty:____________

Address: __________________________________________________

Telephone: __________________________________________________

Fax: __________________________________________________

E-mail: __________________________________________________

 

Yes! I’ll do my part to make SCMS HealthAccess a success. Here’s my

Commitment:

 

During the next year, I will:

 

___ Accept SCMS HealthAccess referrals for ongoing or short term care needs.

 

___ Please contact me. I have additional questions regarding my volunteer role in SCMS HealthAccess.

 

 

 

 

Please fax this form to 235-2385 or mail to PO Box 615, Topeka, KS 66601

 

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