Molokai Ohana Health Care, Inc.

Board Application Form

Welcome and thank you for your interest in the Molokai Ohana Health Care, Inc., dba Molokai Community Health Center.

Brief History: Molokai Ohana Health Care, Inc. (MOHC) was established in 2002 by concerned community members and private/public social service providers to address health care access issues on the island of Molokai. As Molokai’s first federally qualified health center, MOHC’s primary care clinic was opened to see patients in March 2004. Our community health center is mandated to offer primary medical, dental and behavioral health services. Our target population is the uninsured and under insured people of Molokai; however, we are happy to accept insured people too. We welcome all! Services provided at the Molokai Community Health Center are not free. The center accepts most types of insurance plans and patients without insurance. We have staff available to assist people in applying for insurance or for those who qualify, to set up a payment arrangement plan according to a federally mandated “sliding fee scale.” This is a requirement of all federally funded health centers.

MOHC Currently Offers the Following Services:

·  Primary medical care

·  Behavioral health care

·  Dental care

·  Case management (coordinating various treatment and services for patients).

·  Health Education

·  Outreach & Enrollment

·  Enabling Services

·  Family Support Services (Early Intervention)

Mailing Address:

MOHC

P.O. Box 2040

Kaunakakai, HI 96748

553-4500

BOARD COMMITMENT STATEMENTS

Please initial each statement if you agree with the information presented below. We want you to be well informed of board expectations.

Be committed to the organizations mission, vision, and values.
Agree on the vision statement: That all people have optimal, physical, mental and spiritual health.
Agree on the mission statement: To provide and promote accessible comprehensive individual and community health to the people on Molokai with respect and aloha.
Agree on the values statement: All that we do will be done with compassion and aloha to optimize the wellness of our community through the highest quality of care provided with integrity, honesty and respect and commitment to our clients , our community and our organization
Be required to serve on at least one committee and actively participate in all meetings.
Board attendance is a mandate in our bylaws. It is extremely important to stay connected and involved in all board activities.
Commit to approximately 4-10 hour per month.
Willing to be a Molokai Ohana Health Care, Inc. and community advocate.
Be a user or refer others to utilize our healthcare services. (strongly encouraged)
If chosen as a board member you will be asked to give a monetary donation to the organization. The monetary donation is based on what you can afford and what you find meaningful….e.g. $1-$1,000,000.

MAHALO, for taking the time to read and initial above.

Molokai Ohana Health Care, Inc.

Board Application Form

Name:
Address:
City, State, Zip:
Telephone: Cell:
Email:
Occupation:
What is your reason for wanting to serve on this board?
Please review and check all that applies below:
Access and Relationships: / Area of Expertise: / Ethnic Diversity:
0 Political Leaders / 0 Financial Management / 0 Native Hawaiian
0 Philanthropic Leaders / 0 Healthcare / 0 Asian
0 Business Leaders / 0 Human Resources / 0 Caucasian
0 Large Corporations / 0 Legal / 0 Native American
0 Other______/ 0 Planning / 0 Hispanic/Latino
0 Business / 0 African American
0 Faith-Based / 0 Other______
Age: / 0 Public Sector
0 65 and older / 0 Philanthropic / Gender:
0 51-65 0 36-50 / 0 Marketing / 0 Male 0 Female
0 20-35 / 0 Other______
How did you hear about the Molokai Ohana Health Care, Inc. board?
What can you contribute to our organization and board?

List other board involvement.

Name of Organization: / Position Held: / Years:

Personal or professional references.

Name: / Contact Number:

Are you related to any of the current Board of Directors or staff of Molokai Ohana Health Care, Inc.? 0 Yes 0 No

Are you a current user of MOHC, Inc.’s services? 0 Yes 0 No

Please share a brief summary of your community and job experiences

By submitting this application I agree and acknowledge that if selected as a Board of Director member for the Molokai Ohana Health Care Inc. I will be committed to accomplish the organizations Vision, Mission and Values.

Signature:______Date:______

March 2010