REQUEST FOR STATEMENT OF PROFESSIONAL LIABILITY INSURANCE COVERAGE
(PHYSICIANS-IN-TRAINING)

Date:	PID#

Name of Physician:
Department/Division:

Dates of UCSD Appointment in a GME Training Program (month/day/year):

Level	From	To

Ending Date of UCSD Appointment in a GME Training Program (month/day/year):

Complete this section when liability verification is requested for a trainee's rotation to another facility and approval has been granted by the Training Program Director that the offsite rotation is within the course and scope of the trainee's appointment at UCSD.

Name of Facility:
Address:
Rotation Dates to This Facility:

Practice at above named facility approved:


Training Program Director Signature	Date

Future Employment: Complete this section when evidence of liability coverage is requested by an offsite facility/entity for the period of time the trainee was appointed at UCSD Medical Center.

Facility, address, fax and contact person for those requesting evidence of liability coverage:

RETURN TO:

Graduate Medical Education
Mail Code 8829, Fax: 619.543.7850

REQUEST FOR STATEMENT OF PROFESSIONAL LIABILITY INSURANCE COVERAGE
(PHYSICIANS-IN-TRAINING)

GME Related Content

Medical Education Directory

REQUEST FOR STATEMENT OF PROFESSIONAL LIABILITY INSURANCE COVERAGE (PHYSICIANS-IN-TRAINING)

GME Related Content

Medical Education Directory

REQUEST FOR STATEMENT OF PROFESSIONAL LIABILITY INSURANCE COVERAGE
(PHYSICIANS-IN-TRAINING)