(b) An application for registration as a healthcare provider shall include but not be limited to the following:

1. (1) Specific location of the clinic to include street address and city;
2. (2) A statement indicating that the mission of the clinic is to provide free or low-cost services;
3. (3) A list of all medical professionals and their specialties currently providing volunteer services in the clinic;

4. (4) A statement indicating medical professionals delivering services in the clinic:

   1. (A) Are not receiving any financial or other compensation from the clinic; and
   2. (B) Are acting on a voluntary basis;

5. (5) A statement on file that all medical professionals providing services in the clinic:

   1. (A) Have a current professional license; or
   2. (B) Are students under supervision of a person who is licensed in the healthcare profession for which the student is seeking a:

(i) Degree;

1. (ii) License; or

   1. (iii) Certification; and

2. (6)

   1. (A) A copy of the clinic's policy for notifying patients that:

      1. (i) The medical professional is rendering voluntary healthcare services; and
      2. (ii) He or she is immune from civil suit.

   2. (B) This policy must be in language understood by the patient.

      1. (c)
3. (1) The application must be returned to the department.
4. (2) An application meeting the requirements of this part will be approved for a period not to exceed three (3) years.