Provider Volunteers

Thank you for your interest in supporting the COVID-19 Public Health Emergency Response.

Provider Survey

As a volunteer, you will undergo a pre-screening process prior to being referred to one of the NETCCN clinical teams currently supporting COVID-19 responses. The clinical teams will ask for additional information to confirm your credentials and to assign appropriate roles supporting the COVID-19 response.

During the volunteer on-boarding process, you will be asked to provide at least the following:

  • A copy of a current government issued photo ID
  • A copy of a second photo ID
  • Your National Provider Identification (NPI) number
  • Your active and unrestricted Medical License Number and State of Issuance
  • Your valid and active federal DEA registered number

This information will facilitate background checks. Following this process, you will be asked to sign a Volunteer Affirmation Statement to affirm that you acknowledged the minimum expectations of NETCCN volunteers.


  1. Validate that you have a PDF reader with form-completion features.
    Need a PDF Reader? Download a PDF Reader by clicking here.
  2. Download the "NETCCN-002-001-A-Provider-Volunteer-Survey-v-0pt3.pdf" form in pdf format.
  3. Complete the PDF form and save completed survey.
  4. Email the completed survey to:
Download Provider Survey
Provider Survey