SIGNATURE OF AGREEMENT. If I am approved under the Volunteer Health Care Provider Program by the Department, it will be on the truth of the statements contained in this application/protection agreement and related forms. I understand if I provide false information it may nullify the condition of defense and indemnification as provided in 641 Iowa Administrative Code Chapter 88 and it may result in revocation of my eligibility. The INDIVIDUAL VOLUNTEER HEALTH CARE PROVIDER is not protected for volunteer health care services provided prior to the signing of the protection agreement by the Department. Once fully executed, this document serves as the protection agreement between the INDIVIDUAL VOLUNTEER HEALTH CARE PROVIDER and the Department. A fully signed copy will be sent to the INDIVIDUAL VOLUNTEER HEALTH CARE PROVIDER via email or, upon request, by regular mail.
Appears in 4 contracts
Samples: Volunteer Health Care Provider Program Application and Protection Agreement, Volunteer Health Care Provider Program Application and Protection Agreement, Volunteer Health Care Provider Program Application and Protection Agreement
