Healthcare Volunteer Caregiver Form

HEALTHCARE VOLUNTEER CAREGIVER FORM

Client / Patient Information

Client Name:

Date of Birth:    Gender:

Volunteer Caregiver Information

Date of Birth:    Phone:

CPR Certified    First Aid    TB Test Completed    Influenza Vaccine

Weekdays    Weekends    Mornings    Evenings    Overnight

Personal care (bathing, dressing)    Medication reminders only    Meal preparation
Light housekeeping    Transportation / errands    Companionship / supervision

Volunteer has insured vehicle available for client transport    Client consents to volunteer driving client

Medical & Health Information (Client)

Insurance Information (Client)

Background Checks & Volunteer Affirmations

I affirm that I have disclosed all relevant information regarding criminal history, substantiated abuse findings, and other matters that could affect the safety of the client. I authorize any necessary background checks to be conducted as required by the organizing entity.

Background check completed:    Results:

Volunteer acknowledges obligations to report any change in health status, criminal record, or other condition that may impact care:

Confidentiality, HIPAA Authorization & Privacy Acknowledgment

The volunteer caregiver shall maintain the confidentiality of protected health information (PHI) and shall only access, use, or disclose PHI to the minimum extent necessary to provide the agreed services. The volunteer will not share PHI with third parties except as authorized in writing by the client or as required by law.

By signing below, the client authorizes disclosure of pertinent PHI to the volunteer for care coordination and assistance as described in this form. This authorization is limited to information necessary for day-to-day caregiving and does not authorize broader releases.

Client acknowledges receipt of privacy notice and understands the scope of this authorization:

Consent, Release and Indemnification

I, the undersigned client (or legal guardian), consent to the provision of volunteer caregiving services described in this form. I understand that volunteers are not licensed medical providers unless specifically noted and that volunteer assistance is limited to tasks expressly authorized herein. I retain the right to refuse any service at any time and may revoke this authorization in writing.

I release and hold harmless the volunteer, and the volunteer's sponsoring organization, from liability for ordinary negligence in providing non-clinical caregiving services, except to the extent arising from willful misconduct or gross negligence. I agree to indemnify and defend the volunteer and sponsoring organization against claims arising from my failure to provide accurate medical or safety information.

This consent and release shall remain in effect until the Authorization Expiration Date above, or until revoked in writing by the client or legal guardian.

Acknowledgment and Certifications

The volunteer affirms that the information provided herein is true and complete to the best of their knowledge and that they will comply with applicable policies, safety protocols, and training requirements. The client affirms that the medical information provided is accurate and complete to the best of the client's knowledge.

Non-emergency medical tasks such as medication reminders are only to be performed as described and with explicit client consent. The volunteer will notify the client's primary medical provider and emergency contacts if a medical emergency arises.

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