Mercyif DEPARTMENT OF GRADUATE MEDICAL EDUCATION 615 SOUTH NEW BALLAS ROAD CO ELECTIVES/EXTERNSHIPS OVisiting Resident Clonserversmir ST. LOUIS, MO 63141 APPLICATION O_RESIDENT/FELLOW ROTATIONS* (Visiting Medical Student (Please print-follow directions carefully incomplete forms will not be processed) PERSONAL DATA: Name: Cily and Birthdate: State of Birth: Address: Single LJ Married CT Citizenship Male [] Female CJ EMAIL ADDRESS: ‘Emergency Contact Name: ‘Emergency Contact Address: Social Security # Emergency Telephone # EDUCATION: RESIDENCY TRAINING: Current University or Colley Residency Training Hospital: Dates Attended: Degree Awarded: Department: Medical Schoo! Address: Date entered: Date Completed: City/State/Zip Current Level of Training: Current Level of Training: ‘Contact Name & Phone Number Missouri License Number- HEALTH DATA: FLU Shot Date: Trmunization Stats 1) Have you had Diphtheria Tetanus Booster wii te pat ten (10) years? Yes [] No PPD date received: 2) Have you had the Hepatitis B Vaccine series recommended by your School? Yes 0) No O) ‘SIGNATURE OF APPLICANT: DATE: Tam Requesting an: ELECTIVE =O EXTERNSHIP 0 OBSERVERSHIP 0 MUST BE FILED AT LEAST 8 WEEKS IN ADVANCE* (OVER)Dates of requested rotation: Please complete a separate form for each request and mail/email the form(s) directly to the address below (please add in the department name). That department will notify you if you have been approved. PLEASE NOTF: Additional Information is required for Internal Medicine Rotations only. (email Michelle below) Rotation Requested: Requested | Rotation Requested: Requested Month/Year Month/Year Cardiology 7) | Family Medicine i Contact: Michelle | 12680 Olive Bivd. , St. Louis, Mo 63141 | —————~ Enail to: Michelle Kempff@merey.net | Contact: Melissa Phone No. 314-251-5834 Email to.Melissa. Moceri@merey.net Fax No, 314-251-6272 Phone No. 314-251-8950 Fax No. 314-251-8889 Critical Care 7 | Internal Medicine ~ Suite 30198 7 Contact: Sarah —— | Contact: Michelle — Email:Sarah nickerson(@merey.net | Bmail to: Michelle Kempft@merey.net Phone No, 314-251-6930 Phone No. 314-251-5834 Fax No. 314-251-6272 Emergency Medicine 7 | OBIGYN Suite 2009 7 Contact: Janie ———"_ | Contact: Anne cmd Enmail to: Maryjane,Erb@Merey.ne! | Bimail to: Anne.Fitzwitliam@me Phone No. 314-251-6816 Phone No. 314-251-6462 Fax No. 314-251-1601 Fax No. 314-251-4492 Have you ever done a rotation at Mercy Hospital St. Louis? *yesQ)/NoO “If yes: Please list all departments that you have rotated in. Department Date Started Date Ended: Department Date Started: Date Ended: Department ~ Date Stared: Date Ended: ‘This section for (Merey office use only) IS THIS EXTERNSHIP FOR CREDIT? YES] /NO [] Date: Merey Hospital -St. Louis Preceptor’s Name and Signature _ PitNane Signa Please return to: | Mercy Hospital ~ St. Louis Attn: a (lasert Dept., Ste. and Name from above) 615 South New Ballas Road St. Louis, Missouri 63141 IMPORTANT NOTE: the following must be submitted with your application. 1) This form completed for each rotation you request to do at MERCY. 2) Letter from your school stating that you are in good standing and the school will cover your malpractice/liability insurance ($1-3 Million) while rotating @ Mercy- St. Louis. 3) Current Verification of your FLU SHOT & PPD. 4) Corporate Responsibility and Confidential Statement form signed. (Submit all required documents to each department directly that you request a rotation from) missing documentation will delay a respouse. should be. Website address: www.mereygme.net ireoted to eachat Mercy gue Corporate Responsibility and Confidentiality Statement for Visiting Resi: ind dents Corporate Responsibility | understand that Mercy has established a Corporate Responsibility Program to ensure ethical business practices and compliance with applicable laws and regulations. As a member of Mercy's workforce Visiting Student/Resident, | agree to comply with the organizations policies and procedures and code of Conduct. The Corporate Responsibility Hotline number is 314-364-3434 Confidentiality of Patient/Co-worker Information Itis Mercy’s policy (and in most cases legal requirements) that all coworkers/Visiting ‘Student/Resident, protect information regarding patients and other co-workers. No medical information, including the fact that person has been treated in a Mercy facility (or elsewhere), may be released except by authorized persons on a business need to know basis. Any information available to coworkers/Visiting Student/Resident about Mercy patients, including co workers who are patients, must be keep confidential and not discussed with others, including other co-workers, except as needed for medical treatment or to comply with legal processes or legal requirements. Confidentiality of Company Information understand that Merey's Confidentiality policy applies to information pertaining to Mercy operations activities and business affairs, including but not limited to charges, reimbursement rates and contracts. All Mercy information is be maintained in strictest confidence and is not to be discussed with anyone other than appropriate personnel, and may not be shared with others outside the workplace, during my employment, education rotation or post-employment education rotation. Any questions with respect to specific instances of release or discussion of confidential information should be directed to your immediate supervisor System Security J understand that with access to the MercyNet or other merey computer systems, | am responsible to use the system only for work related functions for which | am directly responsible or requested to do by my superiors I may not share my system password with another person, leave the password in an unsecured place, nor sign on to the system for an unauthorized person's use I may only use the single valid system ID that has been assigned to me Visiting Student/Resident-Rotator Print Name Signature Date:‘Medical School or Residency Program Letter Head Date: Mercy Hospital St. Louis, MO " ‘To Whom it May Concern: ays This Letter is to'confirm that JOHN SMITH isin. good standing and currently enrolled as a fourth year Student at Kansas University: ‘This student has been approved to participate in a critical care elective rotation beginning November 2, 2013 at your medical facility. Karisas University maintains medical professional liability coverage for all students collectively while performing duties under the scope of this and other agreements in the minimum amount of 1,000,000 per occurrence and 3,000,000 in the aggregate. \¥ additional information is needed, please fee! free to contact me at: Sincerely, Dean information