Submit a Provider to Our RPCV Health Crusade Provider Directory

Submitter's Name *

Main contact person for the provider listing

Submitter's Email *

Provider's First Name *

Provider's Middle Name

Provider's Last/Family Name *

Provider's Credentials *

Examples include MD, OD, etc.

License Number *

National provider identifier to practice

Year Began Practicing *

Gender *

Female

Male

Non-Binary

Prefer not to disclose

Board Certified? *

Yes

No

Not Applicable for Specialty Area

Race

If multi-racial, list each race on a separate line

Licensed to Practice *

Select all the US states and territories that provider is licensed to practice

Languages *

Which languages (spoken and written) can provider demonstrate an adequate level of fluency to communicate with the patient? List each entry on a different line

Provider's Practice Area *

Select all applicable areas of practice

Provider's Specialty Area(s) *

Provide additional information about provider's specialties and sub-specialties

Provider's Approach to Patient Care

Identifies how provider interacts with the patient

Provider's Facility Name *

Provider's Email *

Multiple contact options help patients with disabilities/limitations

Provider's Website *

Additional Website

Any additional website or online directory listing to share?

Provider's Primary Facility Street Address *

Provider's Primary Facility City *

Provider's Primary Facility State or Territory *

Provider's Primary Facility Zip or Postal Code *

Provider's Primary Phone Number *

Provider's Primary TTY Number

Provider's Primary Fax Number

Provider's 2nd Location Street Address

Provider's 2nd Location City

Provider's 2nd Location State or Territory

Provider's 2nd Location Zip or Postal Code

Provider's 2nd Contact Phone Number

Provider's 2nd Contact TTY Number

Provider's 2nd Contact Fax Number

Online or Email scheduling options? *

Yes (provide the link and/or email in next field)

No

Does provider have digital scheduling methods instead of phone calls?

Webpage or Online Scheduler Link

Provide the link/url for patient to schedule directly online with provider

Email to Schedule Appointments

Provide the email for patient to schedule an appointment with provider

Telehealth or Virtual Sessions Available? *

Yes (identify any needed equipment or applications in next field)

No

Equipment or Applications Required for Telehealth or Virtual Sessions

Identify equipment or programs that the patient needs to communicate virtually; if none, specify NONE

Any medical equipment to loan or give to patient (FREE)? *

Yes (identify the available equipment in next field)

No

Medical Equipment Available to Loan/Give to Patient

List each item on a separate line

Available accommodations for People with Disabilities or Limitations *

(FYI - Many of these are already required by the Americans with Disabilities Act and HIPAA)

Hospital Affiliations

List each entry on a separate line

Insurance Accepted

List all accepted insurance programs. List each entry on a separate line

Provider's Relationship to RPCV Community *

Clarify "other" relationship to RPCV community

If selected "Other", explain how provider has in-depth knowledge of health needs and challenges of RPCVs

Provider's Peace Corps Service Country (Years optional) *

Accepts FECA claims? *

Yes

No

Accepts Peace Corps vouchers? *

Yes

No

Offer free or discounted pricing to uninsured or underinsured RPCVs? *

Yes (identify in next field)

No

Willing to consider (identify in next field)

What special financial arrangements are offered or considered for uninsured or underinsured RPCVs?

Any discounts, barter, or other arrangements available? FREE for RPCVs would be ideal!

Medical Education & Training *

Identify where and when medical training was received (medical school, internship, residency, fellowship, etc.)

Provider's Publications

Use a new line for each entry and include links to any publicly available publication

Provider's Biography

Share any additional background information to help patients learn more about the provider

Provider's Awards & Recognitions

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