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SCMS HealthAccess / Marian Clinic
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 and/or Marian Clinic referrals for ongoing or short term care needs
___ Please contact me. I have additional questions regarding my volunteer role in SCMS HealthAccess / Marian Clinic.
Please fax this form to 235-5114 or mail to PO Box 615, Topeka, KS 66601
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