Physician’s Application

All fields required for submission.

Physician's/Physicians' Name(s):

Email Address:

Type of Practice:

Name of Practice:

Address of Practice:

City:

State:

Zip:

Phone Number:

Website (optional):

In which city do you provide free healthcare? (This does not have to be the same location as your regular practice.)

How long have you been providing this free healthcare?

In at least 100 words, please provide a detailed description of the type of free healthcare that you provide, who benefits, how frequently you perform the service(s), and how you first came to provide the service(s).

What benefits have been realized by the low-income patients as a result of the free healthcare you’ve provided?

Finally, why do you provide this free healthcare?

Comments (optional):

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