Visiting Intern/Residency/Fellowship Application GME McLaren Greater Lansing

Visiting Intern/Residency/Fellowship Application

McLaren Greater Lansing Application for Visiting Intern/Residency/Fellowship Program

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* Indicates required information

Rotation Request

Service requested: *

Preceptor: *

Date of Rotation - From: *
Date of Rotation - To:

Application Date: *

Name (last, first, middle initial): *

Last 4 digits of Social Security number: *

Phone Number (000)000-0000): *

Program year: *

U.S. Citizen: *

Yes

If no, Visa Type:

Licensure
State: *

Year: *

Number: *

State (if applicable):

Year:

Number:

Present Address:

Address: *

City, State, Zip: *

Email: *

Notification Phone (if different from above phone number):

Medical College:

College:

Degree:

Completed:

Address:

City, State, Zip:

Phone (000)000-0000:

PGY I or Internship:

Specialty:

Program Director:

Phone (000)000-0000:

Residency Coordinator:

Phone (000)000-0000:

Residency Coordinator Email:

Hospital:

Expected to Complete or Completed:

Address:

City, State, Zip:

Phone (000)000-0000:

Residency:

Specialty:

Program Director:

Phone (000)000-0000:

Residency Coordinator:

Phone (000)000-0000:

Residency Coordinator Email:

Hospital:

Expected to Complete or Completed:

Address:

City, State, Zip:

Phone (000)000-0000:

Fellowship (if applicable):

Specialty:

Program Director:

Phone (000)000-0000:

Fellowship Coordinator:

Phone (000)000-0000:

Fellowship Coordinator Email:

Hospital

Expected to Complete or Completed:

Address:

City, State, Zip:

Phone (000)000-0000:

Other Post-Graduate Training and Professional Memberships:

(1):

(2):

(3):

Do you have any Physical, Mental, or Substance Abuse Problems which, to your knowledge, could interfere with your ability to perform the essential functions of the job and-or complete the rigorous requirements of Residency Training Program?

Yes

If yes, please describe the problem, related therapy, etc. Send document as necessary):

Do You Have an Armed Services Commitment?

Yes

If yes, please describe:

Comments:

Application Will Be Considered Upon Receipt of the Following:

(a) Part II of the Application from Program Director or Coordinator (download HERE)
(b) Photocopy of your original Internship or Residency Application from current Hospital
(c) Copy of Medical School Diploma
(d) Copy of Current Curriculum Vitae
(e) A certificate of Professional Liability Insurance Coverage for activities to be performed at Ingham Regional Medical Center
(f) Resident/Fellow Current Contract
(g) Photocopy of a valid and current Medical or Osteopathic License, Controlled Substance License and Federal DEA License (if applicable), valid through the time period you are requesting.
(h) Photocopy of current ACGME/AOA Program Approval Letter
(i) Photocopy of ECFMG Certificate (if applicable)
(j) ACLS Certificate

Fax the above info to: 517-975-7880 Attn: Gary Riley
or Email to [email protected]

You can also Mail to:
McLaren Greater Lansing
Medical Education
Attn: Gary Riley
401 W. Greenlawn Ave.
Lansing, Mi 48910

If you have Questions, please call Gary Riley at 517-975-7886

I Agree to:

Perform duties satisfactorily and to the best of my ability under the Medical Education Authority of the hospital.
Conform to all Hospital Policies, Procedures and Guidelines including the Medical Staff Rules and Regulations that are not inconsistent with this policy.
Arrange for housing and all other financial obligations and personal means through my home program. McLaren Greater Lansing assumes no financial obligations for housing, stipend, insurance, or other benefits.
Fulfill all responsibilities and assignments defined by the Chief Instructor of the education experience.
COMPLETE ALL MEDICAL RECORDS required by the Attending Physicians.

If you agree to the above, initial here: *

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