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					           Off-Cycle Visiting Resident/Fellow Rotation
         (Non-KU resident/fellow requesting a patient care rotation at KU)

            Re si de nt ______________________________Depa rt ment _____________________

                           Dates of Rotation at KUSOM:_____________________

   The following is a list of items the GME Office needs before a resident/fellow can be accepted into a visiting
 resident/fellow rotation. The completed packet should be delivered to GME at G019 Robinson, Mail Stop 1060.

             Documentation (photocopies, unless otherwise indicated):
                (Attachment A)- Rotation Schedule and Rotation Goals and Objectives
                (Attachment B-part 1)- Temporary or Permanent Kansas License Certificate
                (Attachment B-part 2)- If rotating in Missouri Hospital Site while visiting KU,
                  Missouri License Certificate
                (Attachment C-part 1)- Kansas DEA
                (Attachment C-part 2)- Missouri BNDD, if applicable
                (Attachment D)- Medical School Diploma or Medical School Transcript with a letter
                  of completion sealed from the Medical School or the ECFMG report
                (Attachment E)- KU Health Information Registration
                (Attachment F)- KU Hospital HIPAA Confidentiality Policy
                (Attachment G)- KU School of Medicine HIPAA Confidentiality Policy
                (Attachment H)- HIPAA Certificate of Training- from home institution
                (Attachment I)- National Provider Information Number
                (Attachment J)- Prior to the visiting resident/fellow finishing their rotation, complete
                  a Clearing Form.

              KUMC Coordinator will prepare the following:
                Complete a Memorandum of Agreement for visiting resident/fellow then circulate for
                 all signatures.
                Set up a Novell GroupWise network account for visiting resident/fellow at
                 http://www2.kumc.edu/email
                Arrange for lab coats and/or pagers, if necessary.
                 *If they plan to rotate through the ED, there is additional eLearning.
                Contact the KUMC Employment Office (8-6629) regarding the ID Badge.
                Add the visiting resident/fellow into E-Value as an Inbound Rotator from another
                 Institution.
                Complete and fax (8-2575) to Linda Wood, if the resident/fellow will be rotating to
                 KUPI (KUPI Chart Audit Card, OIG, EPLS and Disclosure Statement)
                         (KUPI) http://gme.kumc.edu/forms.html
                         (OIG) http://www.oig.hhs.gov/
                         (EPLS) https://www.epls.gov/
                         (Disclosure Statement) http://gme.kumc.edu/forms.html
              MO Institutional DEA and Suffix (call the rotating site to secure a number for this
                resident)
_____________________________________________________________________________________
             GME Office:
              Application and all signatures
              Lori Roop sends email to Cecilia Pivonka-Culver, Elly, Moeller and Acis-Security
                O2 Training, Denise Sessler noting effective date- If visiting residents/fellows are
                expected to use the Electronic Medical Record to document and review charts; they
                will need to go through new provider training. This includes eLearning modules on
                LMS and classroom training. The new provider classroom training is typically every
                other Friday, but if there is a schedule of when to expect them, they MIGHT be able
                to add a class here and there. http://si.netlearning.us/kuhosp
              Lori Roop sends an email to Medical Records Karen Tevault and Theresa Jackson
                That includes NPI and License and effective date.
Visiting Resident/Fellow Rotation
Page 2


                                    Off-Cycle Visiting Resident/Fellow at KU

        THE UNIVERSITY OF KANSAS MEDICAL CENTER MEMORANDUM OF
        AGREEMENT NON-COMPENSATED EDUCATIONAL APPOINTMENT OR
                         ASSIGNMENT (PHYSICIAN)
1)        This agreement approves a visiting rotation at the University of Kansas Medical Center (herein referred to as
          “University”) for <<Visiting Resident’s/Fellow’s Name>>, a resident/fellow in the << KU Program Name>>
          residency training program at <<Name of KU Training Site>>. The rotation will consist of an educational
          experience intended to broaden the resident’s management and experience in providing quality patient care. The
          date of the rotation and agreement are <<Start Date>> to <<End Date>>.

2)        The appointee is assigned to the University of Kansas Medical Center from a sponsoring Graduate Medical
          Education program in <<Visiting Resident/Fellow’s Current Program Name>> at << Visiting
          Resident/Fellow’s current Sponsoring Institution Name>> which will provide full professional liability
          coverage for the visiting resident/fellow.

3)        SUPERVISION
          While at the University, a physician faculty preceptor shall supervise the visiting resident/fellow in
          administrative, educational and patient care activities. Following is the preceptor for the elective rotation at the
          University: <<KU Faculty or Program Director Name>>.
          The Training Site Program Director for the “Training Site” residency program at the University is <<KU
          Program Director Name)>>. By signing this agreement, the “Training Site” Program Director attests that the
          resident/fellow is in good academic standing and is authorized to perform this rotation at the University.

4)        The specific Rotation Goals and Objectives will be included along with the Rotation Schedule on
          (Attachment A).

5)        FISCAL CONSIDERATIONS
          Other than as set forth in this paragraph, University shall make no payments and provide no financial
          accommodation or support to the visiting resident/fellow or to the Training Site.

          Residents/Fellows who participate in the rotation at the University are not considered employees of the
          University, and are not entitled to receive from the University monetary compensation, worker’s
          compensation insurance, and/or any other employee benefits or status. Training Site shall pay the
          visiting resident’s/fellow’s stipend and benefits; otherwise, no party shall make financial contributions
          to the other related to the Agreement.

          Other than as set forth in this paragraph, “Training Site” shall make no payments and provide no financial
          accommodation or support to the University.

6)        BYLAWS, RULES, AND DEPARTMENTAL REGULATIONS
          Residents/Fellows rotating to the University shall agree to observe faithfully the University of Kansas
          GME policy and procedure manual the medical staff bylaws of the University of Kansas Hospital and
          agree to be bound by its terms.

7)        The appointee agrees to not engage in provision of any direct patient care unless licensed on either a
          permanent or temporary basis to practice medicine in the State of Kansas and when applicable a valid DEA
          certificate for the State of Kansas.

8)        While it is anticipated that the term of appointment will be continued for the full period noted above. This
          agreement may be terminated by either party at any time upon written notice of such intent.

9)        EVALUATION OF RESIDENTS/FELLOWS
          Upon completion of the visiting rotation, the University shall provide the program director at the
          Training Site with an evaluation of the visiting resident’s/fellow’s performance.

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10)       GENERAL
          Neither the University nor the Training Site shall discriminate against any resident/fellow participating
          in the program at the Training Site on the basis of race, color, age, religious affiliation, gender,
          national origin, sexual orientation or disability.



Notices required herein shall be sent to:

For the University:

Terance T. Tsue, M.D., FACS
Associate Dean for Graduate Medical Education
University of Kansas Medical Center
Mailstop 1060
3901 Rainbow Boulevard
Kansas City, KS 66160-7301

With a copy to:

Office of Legal Counsel
3901 Rainbow Boulevard
Kansas City, KS 66160-7101


Date__________________              Visiting Resident/Fellow Appointee Signature:____________________________

Date__________________              Visiting Resident/Fellow Program Director Signature: ______________________
                                    Sponsoring Institution Name:_________________________________
                                    Street Address: ____________________________________________
                                    City, State, Zip Code:_______________________________________
                                    Phone Number:____________________________________________

Date__________________              For the University ________________________________________
                                                                        Program Director
                                                              University of Kansas Medical Center

Date__________________              For the University ________________________________________
                                                         Associate Dean for Graduate Medical Education
                                                               University of Kansas Medical Center

                                    Approved as to form:
Date__________________              For the University ________________________________________
                                                                 Associate General Counsel
                                                            University of Kansas Medical Center

Date__________________              For the University ________________________________________
                                                    Executive Dean of Vice Chancellor for Clinical Affairs
                                                             University of Kansas Medical Center




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                                      APPLICATION
                    For Resident/Fellow Rotating From Other Institutions
      For Visiting Resident/Fellow Rotations at the University of Kansas Medical Center
Directions for the applicant: Please complete Section I; have Sections II and III completed by your sponsoring
institution; and attach copies of your Kansas License (MO license and MO BNDD, if applicable), DEA Certificate,
Medical School Diploma, and ECFMG Certificate if applicable.

Return Application to:
         University of Kansas Medical Center Program:________________________________
         Name:_________________________________________________
         Address:_______________________________________________
                   _______________________________________________
         Phone:_________________________________________________

Section I. To be completed by the applicant.
Last Name:_______________________ First Name:____________________ MI: ______ Degree:_______

Date of Birth:__________ Temp. or Perm. KS License #:______________KS DEA #:_________________
                                                     (Attachment B- part 1)        (Attachment C- part 1)
If Rotating in MO:
              MO License #:__________________ MO BNDD #:_____________________
                    (Attachment B- part 2– if applicable) (Attachment C- part 2– if applicable)
SS#:_________________________
Resident/Fellow Rotating to KU has a valid temporary or permanent license in their home program state. __Y __N
**************************************************************************************
Current Residency Institutional Sponsor:_____________________________________________________

Current Residency Program:_______________________________________________________________

Phone #:_____________________ Fax #:________________________ Pager #:_______________________

University of Kansas Medical Center Rotation:______________________ Location:_____________________

Rotation Start Date:_____________________    Rotation End Date:_____________________
*****************************************************************************************
Prior US training– Complete the following:

Prior Residency/Fellowship Program #1:____________________________________________________________

Location (city and state):_________________________ Start Date:____________ End Date:___________

Prior Residency/Fellowship Program #2:____________________________________________________________

Location (city and state):_________________________ Start Date:___________ End Date:____________

****************************************************************************************
Medical School Diploma or Medical School Transcript with a letter of completion sealed from the Medical
School:_________________________________________________ Graduation Date:_________
                          (Attachment D)
If Applicable:
ECFMG Certification #:___________________ ECFMG Certification Date:________________________
                   (Attachment D– if applicable)

________________________________________________                     Date:_____________________
 Resident/Fellow Signature
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Section II. To be completed by the applicant’s current Residency/Fellowship Program Director:
     1.   The resident/fellow named above is in good standing and currently a member of the <<Visiting
          Resident/Fellow’s Current Program Name>> residency/fellowship program.

     2.   On the dates requested for rotation, the resident/fellow is a <<PGY Level>> resident/fellow.

     3.   An evaluation _______ will _______will not be requested at the end of the elective rotation.

     4.   Background Checks:
          The << Visiting Resident/Fellow’s current Sponsoring Institution Name>> will check the following
          databases prior to placing a resident/fellow at KUMC for a clinical rotation:
                           Kansas Highway Patrol Criminal Background Check
                           Other State Criminal Background check (previous residences other than KS in the past
                                seven years) Office of the Inspector General
                           Kansas Sex Offender Registry
                           Other State or National Sex Offender List (previous residences other than KS in the past
                                seven years)
                           Name, Social Security Number and Address Verification
          In cases where the background investigation was not conducted previously, the investigation will then be
          conducted prior to the start of the clinical rotation.
          KUMC will not accept residents/fellows for clinical rotations if their background information revealed any
          convictions for any crime against persons; robbery in the first degree; pharmacy robbery or arson in the
          first or second degrees; felony crimes related to drugs and alcohol; or any other crime that would not permit
          an individual to be licensed or registered by their profession upon completion of the educational program.
          It is the responsibility of <<Visiting Resident/Fellow’s current Sponsoring Institution Name>> to review
          the background information prior to the resident/fellow coming to the Hospital and Sponsoring Institution
          will not send any resident/fellow whose background information does not meet the standards defined in this
          paragraph.

     5. The resident/fellow has our approval to take this elective, and their background check has been completed,
        reviewed and fulfilled state requirements.

                     _______________________________________________________________
                     Residency/Fellowship Current Program Director (Print)

                     _______________________________________________________________
                     Residency/Fellowship Current Program Director (Signature)

                     _______________________________________________________________
                     Sponsoring Institution Name

                     ______________________
                     Date




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Section III. To be completed by an official of the <<Visiting Resident/Fellow’s current Sponsoring Institution
Name>> in whose program the resident/fellow is currently a member:

1. Personal health coverage is in effect while the resident/fellow is away from our program.

2.   KU Hospital HIPAA Confidentiality Policy Compliance is in effect for this resident/fellow. (Attachment F)

3.   Malpractice insurance is extended to cover resident/fellow while the resident/fellow is on this elective rotation.

4. The resident/fellow has our approval to take this elective.

      ___________________________________________                ____________________________________________
      Dean/President/DIO of Sponsoring Institution (print)                       Name of Sponsor

      ____________________________________________ ___________________________________________
      Dean/President/DIO of Sponsoring Institution (signature)    Mailing Address

      _______________________________________ ________________________________________________
      Title                                             City, State, Zip Code

      ______________________________________             ________________________________________________
      Date                                                          Telephone Number




Section IV. To be completed by the University of Kansas Medical Center Residency/Fellowship Program
Director:

The resident/fellow has my approval for the visiting rotation.

KUMC Program:__________________________


________________________________________________
 Residency/Fellowship KU Program Director (Print)

________________________________________________                         Date:_____________________
 Residency/Fellowship KU Program Director (Signature)




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                                                    Attachment E
                                    KU Health Information Registration
                                    (REGISTRATION INFORMATION CHECKLIST)

Name of student/trainee:________________________________________________                  SSN: ___________________
Sponsoring Dept./Div.: _______________________________ Contact:______________                   Phone:_____________
Parent Institution:____________________________________ Contact:______________                  Phone:_____________
                                        University of Kansas Medical Center
                                     Registration Policy for Students or Trainees

Every person participating in any education or training program at the University of Kansas Medical Center must be
registered by the appropriate office on campus. Because of the unique mission of our institution, we have an
obligation to protect patients, employees, and visitors who come in contact with people engaged in education or
training programs. It is important that information about Medical Center policies and procedures be provided. Visiting
students/trainees will be held to the same standards to which we hold our own students, employees, faculty and staff.

COVERED STUDENTS/TRAINEES:
All students, clinical or non-clinical trainees, and visitors or observers of clinical practices or procedures must comply
with the registration policy whether or not university credit or certification is granted.

DEPARTMENTS/DIVISIONS RESPONSIBLE FOR REGISTRATION:
Student Records and Registration: Every person participating in a program or course awarding academic credit
    or leading to a degree, diploma, or certificate from the University will register with the Director of Student
    Records and Registration.

Clinical/Academic Department: Every person not registered with either of the above two offices will be registered
    by the clinical or academic department approving the student/trainee’s presence at the University of Kansas
    Medical Center. This would include but is not limited to clinical trainees performing externships or clerkships,
    guest faculty/staff, or other visitors invited to observe or participate in any aspect of patient care.

The department will ensure completion of the Registration Information Checklist (Appendix A) on each
student/trainee. The checklist must be completed prior to the beginning of training. The checklist is the minimum
information required; therefore, the sponsoring department may request more information as deemed appropriate in
the individual situation. The student/trainee should carry a completed copy of the checklist with them in case
emergency medical services are required.

COMMUNICABLE DISEASES / IMMUNIZATIONS / TESTS
University of Kansas Medical Center requires that the student/trainee be free of any communicable diseases that may
be transmitted to fellow students, patients or employees. Details of required immunization status for Tuberculosis,
tetanus, Rubeola (measles), mumps, rubella, chickenpox and hepatitis B are found in Appendix A. Depending on the
immunization status of the student/trainee, the student/trainee may be given the appropriate immunizations by
Student Health or Occupational Health provided arrangements for payment are made or provided by their primary
care physician. If the student/trainee chooses to decline an immunization that is recommended, they must do so in
writing. Copies of the declinations can be signed in Occupational Health and will be kept with the student/trainee’s
paperwork in the Graduate Medical Education (GME) office.

USE OF UNIVERSITY OF KANSAS MEDICAL CENTER FACILITIES AND SERVICES:
Personal health care services may be provided by KUMC practitioners under guidelines and restrictions as identified
in the individual student/trainee’s personal medical insurance policy.

Visiting students/trainees not eligible to be seen in Student Health and requiring preventive services (immunizations,
PPD, etc.) or care for work-related injuries/exposures (occurring while on campus in the course of performing their
duties) may be seen in the Occupational Health Clinic during normal working hours or in the Emergency Department
after normal working hours, providing payment is guaranteed by the parent institution, sponsoring department or
visiting student/trainee.

RECORDKEEPING
All completed checklists for students/trainees will be kept in a confidential file in the GME office. No services will be
provided without a completed checklist.

ENFORCEMENT

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The checklist must be completed prior to matriculation. If the checklist is not completed, the prospective
student/trainee will be returned to their parent institution and will not be allowed to begin training.
Communicable Diseases and Immunization Status: Do you currently have any infectious disease that could be
transmitted to patients or employees during the normal performance of your duties? Yes                  No
Comments:
                                Immunization or Test                                                    Accurate Date(s)
DPT (Diphtheria, Pertussis,Ttetanus): Two 0.5 ml doses IM (deltoid) 4                    Last Booster Dose
weeks apart; third dose 6-12 months after second dose. Booster every 10
                                                                                         Td:_______________
years or after 5 years for wound management.
Tdap (Tetanus, Diphtheria and Pertussis) Routine: single dose to
replace Td booster ≥10 years earlier. Shorter Interval: > 2 years since last
                                                                                         Tdap:______________
Td booster and care for infants < 12 months old.
MEASLES (Rubeola): documentation of adequate vaccination ( 2 doses                       1)
MMR at least 1 month apart, at or after 12 months of age) or laboratory
                                                                                         2)
evidence of immunity to measles.
                                                                                         Titer:________________
MUMPS: documentation of adequate vaccination (2 doses MMR at least 1                     1)
month apart, at or after 12 months of age) or laboratory evidence of
                                                                                         2)
immunity to mumps.
                                                                                         Titer:________________
RUBELLA (German Measles): documentation of adequate vaccination (2                       1)
doses MMR at least 1 month apart, at or after 12 months of age) or
                                                                                         2)
laboratory evidence of immunity to rubella.
                                                                                         Titer:________________
HEPATITIS B: Two 1.0 ml doses IM (deltoid) 4 weeks apart; third dose 5                   1)
months after second) and positive titer/screen.
                                                                                         2)
                                                                                         3)
                                                                                         Titer:________________
CHICKEN POX (Varicella): documentation of adequate vaccination (Two                      1)
0.5 ml. doses SC 4-8 weeks apart) or laboratory evidence of immunity.
                                                                                         2)
                                                                                         Titer:________________
TUBERCULOSIS: A two-step PPD testing protocol is followed. The first                                    Document below
PPD is administered at start time of rotation. A second PPD (2-step test)
will be needed at a different site in 1-3 weeks, if there is no documentation
of a negative PPD within 12 months preceding the initial test. If history of a
positive PPD test, documentation of a negative chest x-ray within the past
12 months, a negative TB symptoms questionnaire, and description of any
post-conversion treatment is required.
    Previous Skin test Results:
   PPD Skin Test #1: Date Planted:              /       /   Date Read         /      /        Induration (mm):      Negative □
                                                                                                                     Positive □
                                                             Month      Day       Year                      Month   Day Year


   PPD Skin Test #2: Date Planted:          /       /       Date Read         /     /         Induration (mm):       Negative □
                                                                                                                     Positive □
                                                             Month      Day       Year                      Month   Day Year
 If you had a positive TB skin test was a chest X-Ray completed?              □Yes            □No
             If “Yes”: Date of chest x-ray: ______________               Results: __________________________

             Have you ever taken medication for a positive TB skin test?            □Yes      □No
             If “Yes”: Name of Medication: ________________________________                         Length of treatment: _______________


Signature/title of Employee Health Representative_______________________________________ Date__________
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                                                    Attachment F
                                The University of Kansas Hospital Authority
                        CONFIDENTIALITY AGREEMENT/SIGNATURE ATTESTATION

READ CAREFULLY – The University of Kansas Hospital Authority is committed to protecting the privacy and
security of individually identifiable health information, organizational, and other information of a confidential nature
for the hospital organization and its affiliates (collectively known as “confidential information”). As a system user
you hold a position of trust. Information pertaining to patients, confidential information, and other sensitive
information must be held in strict confidence.

All system users at the University of Kansas Hospital are required to read the following agreement and agree to
comply with this Agreement by signing where indicated.

1. I understand that my computer sign-on is my own individual, personal code for gaining access into University of
Kansas Hospital Authority Computer Systems (e.g. SMS, Centricity, Logician, PACS, Tracemaster, etc.) and I agree
that I will not share my login ID and/or password with anyone.
2. My computer sign-on allows me to access only such information which I have been authorized to use to perform
my job responsibilities and I agree that I will only use my computer access as appropriate in order to carry out my
assigned duties.
3. I understand that my computer sign-on and my electronic signature or initials, if applicable, act as my personal
signature, as if I had signed a paper document, when performing all computer activities and is legally binding as my
authorized personal signature.
4. I understand that the information I access through hospital systems is privileged, and/or confidential, and is to be
used only in the performance of job-related or patient-related activities. I agree that I will not divulge confidential
information unless requested to do so by my supervisor or other authorized personnel in the performance of my job
duties or as required by law.
5. I understand that it is a violation of the University of Kansas Hospital’s Medical Record Ownership and
Accessibility Policy to print any confidential information remotely (for example, home, hotel, or any off-site
printer). I agree not to print confidential information remotely.
6. I am responsible for notifying my Human Resources department should I undergo a name change. That way the
sign-on will be kept accurate at all times. I will also notify HIPAA Commitment at extension 5-5490 if I have reason
to believe there may be a breach of confidentiality and/or I have reason to believe someone has accessed and/or is
using my or any other person’s password so that the appropriate action may be taken.
7. I must sign off of a computer system if I leave the computer terminal for any period of time. I understand that
failure to sign off of a Hospital computer system is a violation of the University of Kansas Hospital Authority’s
confidentiality and patient privacy policies. I am responsible for all information accessed with my sign-on.
8. Any user (i.e. employee, staff, student or volunteer), or vendor employee (i.e. Business Associate), viewing
patient information in the course of their job duties must agree to maintain the confidentiality of this information. In
addition, I agree that no medical record is to be removed from the KUMC campus.

I have read this agreement and by signing below I agree to comply with the policies as stated. I understand if I share
my sign-on, use someone else’s sign-on, or fail to comply with this Agreement or any of the Hospital’s
confidentiality or patient privacy policies, I will be committing a breach of hospital policy. I understand that I must
not disclose confidential information, except, as such disclosure is part of the performance of job duties. I further
understand that inappropriate disclosure and/or access of confidential information or any breach of University of
Kansas Hospital Authority confidentiality and privacy policies will result in disciplinary action including possible
loss of access to Hospital Computer Systems and possible termination. My agreement to the above shall continue
even after I leave association with the Hospital or its affiliates.

User’s Signature:_______________________________________________Date:__________________

User’s Name & Title (Print):____________________________________Dept:____________________

Organization (please circle 1):
MAC / MATCS / Jayhawk / Med Center / KUPI / KU Hospital Authority/Other____________



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                                                     Attachment G
                                           KU School of Medicine HIPAA
                                  CONFIDENTIALITY POLICY
                           VISITING FELLOWS, RESIDENTS, STUDENTS

          Patients at KU Medical Center are entitled to confidentiality with regard to their medical and personal
information. The right to confidentiality of medical information is protected by state law and by federal privacy
regulations known as the Health Insurance Portability and Accountability Act (“HIPAA”). Those regulations
specify substantial penalties for breach of patient confidentiality.


     1. All patient medical and personal information is confidential information regardless of the
          educational or clinical setting(s) and must be held in strict confidence. This confidential
          information must not become casual conversation anywhere in or out of a hospital, clinic
          or any other venue. Information may only be shared with health care providers,
          supervising faculty, hospital or clinic employees, and students involved in the care of or
          services to the patient or involved in approved research projects, who have a valid need to
          know the information.
     2. Under strict circumstances, upon receipt of a properly executed medical authorization by
          the patient or a HIPAA-compliant subpoena, medical information may be released to the
          requesting party. Inquiries regarding the appropriateness of the authorization or
          subpoena should be directed to the medical records department or the University’s Office
          of Legal Counsel at 913-588-7281, depending upon the situation.
     3. Computer user codes/passwords are confidential. Only the individual to whom the
          code/password is issued should know the code. No one may attempt to obtain access
          through the computer system to information to which he/she is not authorized to view or
          receive
     4. If a violation of this policy occurs or is suspected, immediately report this information to
          your supervising faculty.
     5. Violations of this policy will result in disciplinary action up to and including termination
          from the program. Intentional misuse of protected health information could also subject
          an individual to civil and criminal penalties.


I, ________________________________, acknowledge receipt of this Confidentiality Policy. I have read the
policy and agree to abide by its terms and requirements throughout my education/training at K.U. Medical Center
and as part of my participation in patient care activities.


Signature_________________________________________ Date ________



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                                              ATTACHMENT A
                                              <<Training Site>>

                                Rotation Schedule and Goals and Objectives




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                                         ATTACHMENT B– part 1
                                           <<Training Site>>

                          Temporary or Permanent Kansas License Certificate




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                                         ATTACHMENT B– part 2
                                           <<Training Site>>

                       If rotating in Missouri Hospital Site while visiting KU,
                                    Missouri License Certificate




\

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                                    ATTACHMENT C– part 1
                                      <<Training Site>>

                                       Kansas DEA




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                                         ATTACHMENT C– part 2
                                            <<Training Site>>

                                    Missouri BNDD (If Applicable)




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                                          ATTACHMENT D
                                          <<Training Site>>

                                    Medical School Diploma or
    Medical School Transcript with a letter of completion sealed from the Medical
                           School or the ECFMG report




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                                            ATTACHMENT H
                                            <<Training Site>>

                         HIPAA Certificate of Training- from home institution




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                                               ATTACHMENT I
                                               <<Training Site>>

                                    National Provider Information Number




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                                                 ATTACHMENT J


                                    Visiting Resident/Fellow Clearing Form


 INSTRUCTIONS: Obtain the signatures of the departments or individuals listed below. Return this
 form to your Residency Coordinator by the last day of training. The Residency Coordinator is to
 provide the Graduate Medical Education Office with a copy prior to the completion of your visit.

                            Clearance Item                                   Signature
 Archie Dykes Library-Fines or Outstanding Materials
 Front Desk
 Identification Badge Turn-In
 Human Resources
 Additional Affiliates:
 Keys (Department)
 Program Coordinator
 Additional Affiliates:
 Medical Records-KU Hospital
 Additional Affiliates:
 Medical Records-KUPI
 Additional Affiliates:
 Pager--TURN OFF VOICEMAIL FORWARDING
 Program Coordinator
 Parking Services
 Support Services Facility, 2100 W. 36th Ave
 Duty Hours Logging Complete in E*Value
 Program Coordinator
 Provide Program with New Address
 Program Coordinator
 Meal Card - KU Hospital
 Program Coordinator




Revised 1/20/2011                                       19
KUMC Legal Review: 10/20/2009

				
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