• Thank you for your interest in becoming a patient at Volunteers in Medicine (VIM). To qualify, you must live in Comal or Guadalupe County, and fall below our income guidelines. 

    Once you complete the application below, please bring in proof of residency (driver's license or lease agreement in your name) and household income (last 4 paycheck stubs, last year's tax return, food stamp award letter, disability, child support...) 

    Please call the office if you have any questions. 

  • Thank you for applying. At this time you do not qualify to be a patient. Please call the office at 830-632-5131 if you wish to discuss further. 

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  • I certify that the information I have given is up-to-date and correct.  I understand that any falsification, misrepresentation, or withholding of information may result in the loss of eligibility to receive clinic services.

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  • Consent to Treatment by Volunteers in Medicine Staff and Volunteer Medical Professionals

    I understand that services I receive from Volunteers in Medicine providers is free of charge.

    I understand that state and federal law imposes a limitation on the recovery of damages from such a volunteer clinic in exchange for receiving health care services.  Those limitations include immunity from civil liability for any act or omission resulting in death or injury to a patient if:

    1.    The employee and/or volunteer was acting in good faith and in the course and scope of the provider's duties or functions within the organization;

    2.   The employee and/or volunteer commits the act or omission in the course of providing health care services to the patient;

    3.   The services provided are within the scope of the license of the employee and/or volunteer; and before the employee and/or volunteer provides health care services, the patient (or if the patient is a minor or is otherwise legally incompetent, the patient’s parent, legal guardian, or other person with legal responsibility for the care of the patient) signs a written statement that acknowledges;

    a.   That the employee and/or volunteer is providing care that is not being compensated by the patient;

     

    I HAVE READ AND UNDERSTAND THE ABOVE AND ACKOWLEDGE THAT I WILL BE TREATED BY AN EMPLOYEE AND/OR VOLUNTEER MEDICAL AND/OR DENTAL PROFESSIONAL, UNDERSTANDING THE LIMITATIONS ON THE RECOVERY OF DAMAGES DESCRIBED ABOVE FOR PATIENT.

    AUTHORIZATION FOR TREATMENT

    I HEREBY AUTHORIZE VOLUNTEERS IN MEDICINE STAFF AND VOLUNTEER PROFESSIONALS TO TREAT ME (IF PATIENT IS UNDER 18 YEARS OF AGE, PARENT MUST SIGN.)

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  • Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

     

    The undersigned acknowledges review of a copy of the currently effective Notice of Privacy Practices for Volunteers in Medicine. A copy of this signed and dated Acknowledgment shall be as effective as the original. The undersigned may request a copy of the Notice of Privacy Practices.

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  • Please list any parties who can have access to your healthcare information.
             
             
             

  • Release Form for Health and Financial Information

  • I,   *   *   , give my consent for Volunteers in Medicine to release/receive any or all health/financial information from/and to other providers. 

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