Get Postdoctoral Scholar Patient Care Information Sheet

Filling out the POSTDOCTORAL SCHOLAR PATIENT CARE INFORMATION SHEET is a vital step for individuals engaging in postdoctoral research with patient contact. This guide will provide comprehensive, step-by-step instructions to assist you in completing this form accurately and efficiently online.

Follow the steps to effectively complete the patient care information sheet.

1. Click the 'Get Form' button to access the POSTDOCTORAL SCHOLAR PATIENT CARE INFORMATION SHEET and open it in an editor.
2. Begin by filling out the 'Name' section, which includes the last name, first name, and middle initial of the postdoctoral fellow.
3. Enter the 'Social Security #' of the fellow in the designated field.
4. Complete the 'Department/Division' and 'Specialty' fields, providing the relevant information pertaining to the fellow's area of work.
5. List the 'Degree(s) Completed' by indicating whether the fellow holds an MD or PhD. Also, provide the name of the previous institution attended and the graduation date in the specified format (mm/dd/yyyy).
6. Confirm the nature of patient contact by selecting one of the options presented: (1) No patient contact during fellowship, (2) May have incidental patient contact, or (3) Full patient care responsibilities. Make sure to initial your selection.
7. Indicate whether this position is an accredited fellowship, and if applicable, specify the type of accreditation (ACGME, ABMS, or other).
8. Answer whether a request for billing privileges will be submitted for the postdoctoral fellow and provide necessary attachments if applicable.
9. For MDs, include the 'Expiration Date' and 'California Medical License #' along with attaching required documents such as the medical school diploma and medical license.
10. Fill in the 'Postgraduate Year' and provide details regarding previous training including specialty and location for each year from PGY I to PGY V.
11. Finally, the postdoctoral fellow must sign and date the form. The faculty sponsor also needs to provide their name, title, and signature.
12. Review all the information entered for accuracy. Once confirmed, submit the original copy to the Office of Postdoctoral Affairs (OPA) and maintain a copy for departmental records. You can also save changes, download, print, or share the form as needed.

Complete your POSTDOCTORAL SCHOLAR PATIENT CARE INFORMATION SHEET online today to ensure a smooth onboarding process.