Forms, Policies, and Notices

Housestaff

Policies and Guidelines

UCSD Medical Center Terms and Conditions of Appointment Document - [570 kb]

House Officer Policy and Procedure Document - [201 kb]

Academic Policies, Procedures, and Guidelines  - [718 kb]

Licensure and Registration

Request for Examination and Board Action History Report (EBHAR) ( ONLINE FORM   |  PAPER FORM )

USMLE Step 3 Registration ( ONLINE FORM   |  PAPER FORM )

New Residents

1. State Oath of Allegiance and Patient Agreement, UPAY585 (R11/2011) - [803 kb]
2. Application - [119 kb]
3. Dean's Report - [522 kb]
4. Report of Performance - [518 kb]
5. Acknowledgement of Child Abuse Reporting & Elder/Dependent Adult Abuse Report form - [75 kb]
6. W-4 - [455 kb]
7. W-4 Non-Resident: Please contact campus payroll at 858-534-3247
   
8. Payroll Wage Distribution Request - [54 kb]
9. Statement Concerning Your Employment in a University Position Not Covered by Social Security - [32 kb]
10. Employment Eligibility Verification form I-9 - [379 kb]
11. Certificate of Foreign Status for Federal Tax Withholding - [6506 kb]

Visiting Residents

1. UCSD Resident/Fellow Position Description 
2. HIPAA Memorandum
3. Information Security Awareness Information Sheet
4. Acknowledgement of HIPAA Training 
5. HIPAA Confidentiality Agreement 
6. California Medical License Registration Form - Non-Navy Applicant - [111 kb]
7. California Medical License Registration Form - Navy Applicant 
8. UCSDs Standards of Business Conduct Acknowledgement Form - [1560 kb]

HIPAA

HIPAA Memorandum

Information Security Awareness Information Sheet

HIPAA Confidentiality Agreement 

Acknowledgement of HIPAA Training 

UCSD Minimum Security Standards

Benefits

Active Trainees

Rotating Liability Request Form 

Moonlighting Liability Request Form 

Anthem Blue Cross Enrollment Form - [166 kb]

Anthem Blue Cross Change Form - [75 kb]

Anthem Blue Cross Affidavit of Domestic Partnership  - [101 kb] 

Standard Insurance Enrollment and Change Form  - [185 kb]

Vision Services Plan Enrollment Form  - [119 kb]

COBRA

Notice of Right to Elect Continued Health Coverage

Standard Life Insurance Group Conversion Packet

Standard Group Conversion Request for Long Term Disability Insurance

Notice to Terminating Employees

Important Notice Regarding COBRA Coverage

Program Directors

Sample Template for Departmental/Program Use - [26 kb]

Description of Internal Review Process  - [58 kb]

Program Coordinators

Affiliate Reimbursement Billing Form - [123 kb]

UPAY585 (R11/2011) - [803 kb]

Acknowledgement of Child Abuse Reporting & Elder/Dependent Adult Abuse Report form - [75 kb]

Employment Eligibility Verification form I-9 - [960 kb]

Academic Biography - [89 kb]

Certificate Request Form - [27 kb]

Monthly Summary Sheet

Instructions to convert ERAS file to text file -[312 kb]

Program Letter of Agreement Template  - [60 kb]

Name Change Request Form  [45 kb]

Taxi Cab Reimbursement  - [303 kb]

Medical License Matrix [13 kb]

Request for J1 Visa Sponsorship - [48 kb]

Slot Designation Form  - [6,758 kb]

New Appointee Checklist

• Anesthesia - Ophthalmology and Pharmacy  - [53 kb]
• Anesthesia - Ophthalmology and Pharmacy (Internal Transfers Only) - [59 kb]
  
• Orthopaedic Surgery - Urology  - [59 kb]
• Orthopaedic Surgery - Urology (Internal Transfers Only) - [59 kb] 

New Programs and Program Changes

Complement Increase Worksheet   -[36 kb]

New Program Worksheet  - [39 kb]

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