Partners In Care Application

Welcome to Community Health Network's Partners In Care Program application!

Please fill out this application in its entirety. Any missing information may result in a delay in processing. Please note, this is an unpaid volunteer position, if you're looking to apply for employment please visit eCommunity.com/careers. Thank you.

Have questions about Partners in Care? View our Frequently Asked Questions.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Information:

* Legal First Name

Middle Name

* Legal Last Name

Name Suffix

Preferred Name

* Street Address

Apartment / Suite

* City

State

* Zip / Postal

* Birthday:

Race

Ethnicity

Legal Sex

Gender Identity

Marital status

Household Income

Shirt Size / Fit

If you were referred to this program, who referred you?

Contact Information:

* Primary Phone Number

Secondary Phone Number

* E-mail

Best day/time to reach you?

Best way to reach you?

Care Experiences at Community:

Have you or any of your family member(s) received care at Community Health Network?

Where did you or your family member(s) receive care at Community Health Network?

Are you a current employee of Community Health Network?

More About You:

* Why are you interested in becoming a Patient Experience Partner or serving on a Patient and Family Advisory Council?

* What do you consider to be your personal strengths useful to this program and how would they be applied?

* What topics or areas of interest do you have in healthcare?

* What does the ideal healthcare experience look like to you?

Consent Forms:

Are you willing to sign a Volunteer Confidentiality Agreement? (This agreement states you will not share any information learned or discussed during Patient and Family Advisory Council meetings, committee meetings, cabinet meetings, other council meetings, work group meetings, etc.)

Are you willing to sign an Authorization for Release of Personal Health Information to a Third Party Form? (This form allows Community Health Network to discuss and share patient and family member experiences if they choose to go on record to do so.)

Are you willing to sign a Permission to Photograph Form? (This form allows Community Health Network to video or photograph any meetings or storytelling of patient and family member experiences.)

Are you willing to consent to a Criminal Background Check?

Have you ever been discharged from any position?

If yes, explain:

Have you ever been convicted of a crime (felony and/or misdeameanor)? You must include driving violations involving the use of illegal substances or cases sealed or expunged by a court.

If yes, please list the charge/offense, date, arresting agency/location, and court disposition.

Do you have any criminal charges pending?

If yes, please give the date and nature of all pending charges.

Have you lived in Indiana for 2 years?

I certify the statements on this application are true and correct to my knowledge. I certify that I am not currently debarred, excluded, or otherwise ineligible for participation in federal health care programs. I understand that falsification, misrepresentation, or omission of information requested on this application will result in immediate dismissal, regardless of the date of discovery. I understand the Network will make a thorough investigation, including a criminal history investigation, of my entire personal history and may verify all data given in my application. I authorize such investigation and the giving and receiving of any information required by the Network. I release from liability any person giving or receiving such information now or in the future. I understand falsification of data given or derogatory information discovered as a result of this investigation may prevent my being accepted as a Patient Partner, or, if accepted, may subject me to immediate dismissal. I also acknowledge and understand this application is not a contract of employment, and that if I am accepted as a Patient Partner, I will be an at-will volunteer and may voluntarily leave my volunteer position upon proper notice. I understand that my volunteer position may be terminated at any time for any reason. I acknowledge that no written or oral statements or promises have been made to or relied upon by me regarding the length of my volunteer position or the reasons for which my volunteer position can be terminated. If accepted as a Patient Partner, I agree to abide by and conform to all rules, policies, and procedures of Community Health Network.

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Applicant Signature

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