Get External Moonlighting Request Form Request For Permission To ... - Mediasrc Bcm

Filling out the External Moonlighting Request Form is an essential step for trainees wishing to seek permission to engage in additional work outside Baylor College of Medicine. This guide provides clear instructions to help you navigate the process efficiently.

Follow the steps to successfully complete your external moonlighting request.

1. Press the ‘Get Form’ button to access the form. This will allow you to open the document in an online format, ready for completion.
2. Fill in the dates of work you are requesting, ensuring to include both the start and end dates.
3. Indicate your current PGY level and provide your name, phone number, and pager number in the designated fields.
4. Specify your Graduate Medical Education department or program and include your Texas Medical License number. Be sure to attach copies of your license, DEA, and DPS as required.
5. Enter the requested work time in hours per week and provide your end of training date to provide context for your request.
6. Complete the requested work dates section, ensuring that both the start and end dates are filled in accurately.
7. Provide the place of work, the source of your salary, and the source of your malpractice insurance.
8. List the names of any employing or attending physicians who will be supervising you during your external moonlighting activities.
9. Ensure to read the provided terms regarding your Texas Medical License and malpractice insurance responsibilities before signing.
10. Sign the form as a house officer and obtain all necessary approvals from the BCM Department Program Director, BCM Risk Management, and Parent Program Director.
11. Once completed, save your changes, then download, print, or share the form as required for submission.

Complete your External Moonlighting Request Form online today to ensure your professional pursuits outside Baylor College of Medicine are properly authorized.