One Medical Center Drive
Lebanon, NH 03756
Phone:
(603)650-5748
Fax: (603)650-5754
Welcome, DHMC House Staff!
The Graduate Medical Education staff looks forward to your arrival this season.
The forms in this document are NOT included in the mailed packet and must be printed, filled
out and promptly sent back to the Graduate Medical Education Office at DHMC, 1 Medical
Center Drive, Lebanon, NH 03756. A large, brown postage-paid return envelope is included in
mailing for this purpose. **Exception: Please note that the Occupational Medicine Health
Questionnaire, the last document below, should be mailed back in the separate white business
reply envelope to the Occupational Medicine Office, for privacy purposes.

If you experience any difficulties, call Chris or Denise at 603-650-5748. Check boxes are
provided to help you keep organized with completion.

GME DATA FORM 
This information is needed to complete your GME record.
EMPLOYMENT QUESTIONNAIRE

Please complete all questions then sign and date the form.

NH MEDICAL TRAINING LICENSE
This form needs to be filled out in order for you to obtain a Resident in Training license from the state of New
Hampshire. It is required for all residents and fellows training in New Hampshire that do not currently hold a
full NH License.
Please read the directions carefully, especially if you already have a permanent license in another state. A list
of addresses of all State Medicine Boards is available at this website. You are responsible for having
original copies of your NBME, NBOME, FLEX, COMLEX or ECFMG scores sent directly to the NH
Board of Medicine. You must have finished and passed both Step 1 and Step 2 CK & CS, or their
equivalent.

MEDICAL INSURANCE ENROLLMENT FORM
The form entitled “Mary Hitchcock Memorial Hospital Application for Health Coverage” is for your
enrollment in our medical insurance plan. The plan is administered by Anthem/Blue Cross. Coverage will
start July 1st if you begin training in June or July 1st. If you begin on July 2 through July 31, your coverage
begins the first day of the next month, August 1st. Please be sure your current medical insurance covers
you until the time our medical coverage begins.
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AFFIDAVIT OF DOMESTIC PARTNER RELATIONSHIP
If you will be will be including a domestic partner on your insurance, both you and your partner need to fill
out the affidavit.
Welcome, DHMC House Staff…Page 2

HOUSE STAFF BENEFITS ELECTION FORM
This form is used to ensure that you receive health and dental (if you choose dental) insurance coverage. Read
the directions carefully and be sure to fill in all spaces with the codes to indicate if you need single, you and
spouse/domestic partner, you and one child, or family coverage, etc. If you do not choose dental at this time
you cannot sign up for dental coverage again until October 2006 for coverage which begins January 2007.
Dental insurance is optional. If you choose this coverage the hospital pays 50% of the cost of dental insurance
and you pay 50%. The 2005-2006 rates are:
Your Cost
Single coverage
Two Person
Family
$130.00 per year
$240.00 per year
$390.00 per year
The payments are deducted from your biweekly stipend check in equal increments.
GE GROUP LIFE ASSURANCE
Be sure to fill in your name and the names of primary and contingent beneficiaries. This means you put a
name in the first box, and should you and that person(s) expire at the same time, the life insurance benefit
goes to the contingent beneficiary. You must choose and fill in the beneficiary spaces. This life insurance is
provided at no cost to you and is equal to your annual stipend.

CLINICAL INFORMATION SYSTEM FORM
Fill this out according to the attached instructions. We want you to be able to get into the computer system on
your first day of training and need this form to do so.

COAT & SIGNATURE FORM - 2-Part Form
Graduate Medical Education will allot incoming residents two white lab coats a year with the DHMC logo
embroidered on. It takes months to order your coats, so please write down your coat size and return to GME.
Women should refer to the chart on the form to find the corresponding unisex coat size. Make sure to take
into account what type of clothing you tend to wear underneath. (ie: sweaters, light shirt, etc)
In the space on the form marked for your signature, sign your name as you will be signing it on medical
records. LEGIBLY PRINT your name underneath your signature.

W-4 FEDERAL TAX FORM
Please complete the form so that MHMH can withhold the correct Federal income tax from your pay.

W-4 VERMONT
Please fill out this sheet if you reside in the state of Vermont. Fill in the same information you provided on
your Federal W-4.

OCCUPATIONAL MEDICINE WORKPLACE HEALTH QUESTIONNAIRE
Please fill this out to the best of your ability. Please mail this questionnaire and proof of immunity to
Rubella, Rubeola, Chicken Pox, Hepatitis B, and Tuberculosis in the white business reply envelope
provided in your mailed packet to the Occupational Medicine Department. Nurses from the Occupational
Medicine Office will check these immunities for you at orientation if you do not have proofs of
immunization: However, we encourage you to have this all in order prior to Orientation.
Dartmouth Medical School • Dartmouth-Hitchcock Clinic • Mary Hitchcock Memorial Hospital • V.A. Medical Center, White
River Junction, VT
Dartmouth Medical School • Dartmouth-Hitchcock Clinic • Mary Hitchcock Memorial Hospital • V.A. Medical Center, White
River Junction, VT