If you'd like to volunteer with Health Access Initiative (HAI), please complete the form below.  We will contact you to discuss how you can help us care for uninsured adults in Hall County.
 

Date:

Name:

Practice Name:

Specialty:

Contact person who will be handling Health Access Initiative coordination in your office:

Name:

Telephone Number:    Fax:   

E-mail Address:

Yes! I will do my part to make HAI a success, decreasing the number of medically underserved individuals in Hall County! Here's my pledge:

I agree to provide a medical home for patients per month (we suggest 2-4 patients per month).

I agree to provide specialty care for patients per month (we suggest 4-6 patients per month).

I agree to support HAI and partnering agencies with medication samples. I request pickup of donated samples every (day and time/list am or pm).

This signed HAI pledge form acknowledges that the health Care provider will render medical services voluntarily and without compensation to qualified HAI patients.

Signature:   Date: