Visiting Resident/Fellow Rotation
(Non -K U resident/fellow requesting a patient care rotation at KU)
R e s i de n t ______________________________D e p a r t me n t _____________________
Dates of Rotation at KUSOM:_____________________
The following is a list of items the GME Office needs before a resident/fellow can be accepted into a visiting
resident/fellow rotation. The completed packet should be delivered to GME at 1140 Delp, Mail Stop 1060 at least
two weeks prior to the visiting rotation.
KUMC COORDINATOR WILL PREPARE THE FOLLOWING:
 Step 1: Complete a Memorandum of Agreement (pages 3-7) for visiting resident/fellow, circulate for
signatures, and then start collecting all applicable attachments from the visiting resident/fellow.

Step 2: Set up an Outlook network account for the visiting resident/fellow at
http://www2.kumc.edu/accounts/visitingfaculty-researcher.html.

Step 3: Complete a Hospital O2 Computer Access (resident/fellow) Request Form.
(see Attachments F & G)
 Step 3.a: Send form to GME for Assistant Dean signature of approval. GME will fax attachments F
& G and then notify you once complete.
 Step 3.b: After GME has notified you, request O2 Training at O2trainingrequests@kumc.edu
 Step 3.c: If rotating through the ED, there is additional eLearning for O2 training (Electronic Health
Record) at http://si.netlearning.us/kuhosp

Step 4: Set up an appointment with Occupational Health (8-6512).
(see Attachment E)
Appt. Date/Time:__________________
Inform the Resident/Fellow to bring the following to their appointment:

Photo ID

Medical Records- see attached page 14 for details

Step 5: Complete and fax (8-2575) the following to the Director of Compliance and Privacy:
Initial____ Date___________

UKP Chart Audit Card (see PC Toolkit-New Residents Onboarding Tools folder)

OIG http://www.oig.hhs.gov/

EPLS https://www.sam.gov

Disclosure Statement (see PC Toolkit-New Residents Onboarding Tools folder)
 Step 5.a: If visiting resident/fellow is at KU for 45 days or less, please follow this link to complete
the required UKP Billing Compliance Training: https://www2.kumc.edu/chalk3
-OR Step 5.b: If visiting resident/fellow is at KU for 45 days or more, please contact the UKP Billing
Compliance Office (8-6629) to schedule In-person training.

Step 6: Notify Medical Records.
Initial____ Date___________

Email the following information to HIMNewProvider@kumc.edu and cc: GME: Name,
Email, NPI # and Dates of Rotation.

Step 7: Add and Schedule the visiting resident/fellow into E*Value (Bio Data and Training and Edu. tab)
Initial____ Date___________

Step 8: Contact the KUMC HR Employment Office (8-5086) for an ID Badge.
Initial____ Date___________
Miscellaneous:
 Step 9: Arrange for lab coats and/or pagers, if applicable.
 Step 10: Contact the MO rotating site to secure a MO Institutional DEA and Suffix number for your
visiting resident/fellow, if applicable.
 Step 11: (Attachment L) Prior to the visiting resident/fellow finishing their rotation, ensure a Clearing
Form is completed
Checklist continued on page 2
Visiting Resident/Fellow Rotation
Page 2
VISITING RESIDENT/FELLOW RESPONSIBILITIES:
Provide the following documentation to your KUMC Coordinator:

(Attachment A)- Rotation Schedule and Rotation Goals and Objectives

(Attachment B-part 1)- Temporary or Permanent Kansas License Certificate

(Attachment B-part 2)- If rotating in Missouri Hospital Site while visiting KU, Missouri License
Certificate

(Attachment C-part 1)- Kansas DEA

(Attachment C-part 2)- Missouri BNDD, if applicable

(Attachment D)- Medical School Diploma, or Medical School Transcript with a letter of completion
sealed from the Medical School or the ECFMG report

(Attachment E)- KU Health Information Registration (Occupational Health)- see KU Program
Coordinator

(Attachment F)- Hospital O2 Computer Access (resident/fellow) Request Form- see KU Program
Coordinator

(Attachment G)- KU Hospital Confidentiality Policy- signature required

(Attachment H)- KU School of Medicine HIPAA Confidentiality Policy- signature required

(Attachment I)- HIPAA Certificate of Training- from home institution

(Attachment J)- National Provider Information Number

(Attachment K)- Proof of Malpractice Insurance/Certificate ($1,000,000/$3,000,000)

(Attachment L)- Clearing Form- see KU Program Coordinator
*Any incomplete items will delay the visiting resident/fellow start date
_____________________________________________________________________________________________




GME OFFICE USE ONLY:
Review completed packet and GME signatures
Assistant Dean sign O2 form/fax with Attachment G to 8-8562 and contact O2 Security
Review E*Value Setup for Cost Report
Collect Occupational Health Clearance Form
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Visiting Resident/Fellow at KU
THE UNIVERSITY OF KANSAS MEDICAL CENTER
MEMORANDUM OF AGREEMENT
NON-COMPENSATED EDUCATIONAL APPOINTMENT OR ASSIGNMENT
(PHYSICIAN)
1)
This agreement approves a visiting rotation at the University of Kansas Medical Center (herein referred to as
“University”) for <<Visiting Resident’s/Fellow’s Name>>, a resident/fellow in the << KU Program Name>>
residency training program at <<Name of KU Training Site>>. The rotation will consist of an educational
experience intended to broaden the resident’s management and experience in providing quality patient care. The
date of the rotation and agreement are <<Start Date>> to <<End Date>>.
2)
The appointee is assigned to the University of Kansas Medical Center from a sponsoring Graduate Medical
Education program in <<Visiting Resident/Fellow’s Current Program Name>> at << Visiting
Resident/Fellow’s current Sponsoring Institution Name>> which will provide full professional liability
coverage for the visiting resident/fellow.
3)
SUPERVISION
While at the University, a physician faculty preceptor shall supervise the visiting resident/fellow in
administrative, educational and patient care activities. Following is the preceptor for the elective rotation at the
University: <<KU Faculty or Program Director Name>>.
The Training Site Program Director for the “Training Site” residency program at the University is <<KU
Program Director Name)>>. By signing this agreement, the Visiting Resident’s/Fellow’s Program Director
attests that the resident/fellow is in good academic standing and is authorized to perform this rotation at the
University.
4)
The specific Rotation Goals and Objectives will be included along with the Rotation Schedule on
(Attachment A).
5)
FISCAL CONSIDERATIONS
Other than as set forth in this paragraph, University shall make no payments and provide no financial
accommodation or support to the visiting resident/fellow or to the Training Site.
Residents/Fellows who participate in the rotation at the University are not considered employees of the
University, and are not entitled to receive from the University monetary compensation, worker’s
compensation insurance, and/or any other employee benefits or status. Training Site shall pay the
visiting resident’s/fellow’s stipend and benefits; otherwise, no party shall make financial contributions
to the other related to the Agreement.
Other than as set forth in this paragraph, “Training Site” shall make no payments and provide no financial
accommodation or support to the University.
6)
BYLAWS, RULES, AND DEPARTMENTAL REGULATIONS
Residents/Fellows rotating to the University shall agree to observe faithfully the University of Kansas
GME policy and procedure manual the medical staff bylaws of the University of Kansas Hospital and
agree to be bound by its terms.
7)
The appointee agrees to not engage in provision of any direct patient care unless licensed on either a
permanent or temporary basis to practice medicine in the State of Kansas and when applicable a valid DEA
certificate for the State of Kansas.
8)
While it is anticipated that the term of appointment will be continued for the full period noted above. This
agreement may be terminated by either party at any time upon written notice of such intent.
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9)
EVALUATION OF RESIDENTS/FELLOWS
Upon completion of the visiting rotation, the University shall provide the program director at the
Training Site with an evaluation of the visiting resident’s/fellow’s performance.
10)
GENERAL
Neither the University nor the Training Site shall discriminate against any resident/fellow participating
in the program at the Training Site on the basis of race, color, age, religious affiliation, gender,
national origin, sexual orientation or disability.
Notices required herein shall be sent to:
For the University:
Associate Dean for Graduate Medical Education
University of Kansas Medical Center
Mailstop 1060
3901 Rainbow Boulevard
Kansas City, KS 66160-7301
With a copy to:
Office of Legal Counsel
3901 Rainbow Boulevard
Kansas City, KS 66160-7101
Date__________________
Visiting Resident/Fellow Appointee Signature:____________________________
Date__________________
Visiting Resident/Fellow Program Director Signature: ______________________
Sponsoring Institution Name:_________________________________
Street Address: ____________________________________________
City, State, Zip Code:_______________________________________
Phone Number:____________________________________________
Date__________________
For the University ________________________________________
Program Director
University of Kansas Medical Center
Send completed packet to GME for these signatures:
Date__________________
Date__________________
Date__________________
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For the University ________________________________________
Associate Dean for Graduate Medical Education
University of Kansas Medical Center
Approved as to form:
For the University ________________________________________
Associate General Counsel
University of Kansas Medical Center
For the University ________________________________________
Executive Dean of Vice Chancellor for Clinical Affairs
University of Kansas Medical Center
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APPLICATION
For Resident/Fellow Rotating From Other Institutions
For Visiting Resident/Fellow Rotations at the University of Kansas Medical Center
Directions for the applicant: Please complete Section I; have Sections II and III completed by your sponsoring
institution; and attach copies of your Kansas License (MO license and MO BNDD, if applicable), DEA Certificate,
Medical School Diploma, and ECFMG Certificate if applicable.
Return Application to:
University of Kansas Medical Center Program:________________________________
Name:_________________________________________________
Address:_______________________________________________
_______________________________________________
Phone:_________________________________________________
Section I. To be completed by the applicant.
Last Name:_______________________ First Name:____________________ MI: ______ Degree:_______
Date of Birth:__________ Temp. or Perm. KS License #:______________KS DEA #:_________________
(Attachment B- part 1)
(Attachment C- part 1)
If Rotating in MO:
MO License #:__________________ MO BNDD #:_____________________
(Attachment B- part 2– if applicable) (Attachment C- part 2– if applicable)
SS#:_________________________
Resident/Fellow Rotating to KU has a valid temporary or permanent license in their home program state. __Y __N
**************************************************************************************
Current Residency Institutional Sponsor:_____________________________________________________
Current Residency Program:_______________________________________________________________
Phone #:_____________________ Fax #:________________________ Pager #:_______________________
University of Kansas Medical Center Rotation:______________________ Location:_____________________
Rotation Start Date:_____________________
Rotation End Date:_____________________
*****************************************************************************************
Prior US training– Complete the following:
Prior Residency/Fellowship Program #1:____________________________________________________________
Location (city and state):_________________________ Start Date:____________ End Date:___________
Prior Residency/Fellowship Program #2:____________________________________________________________
Location (city and state):_________________________ Start Date:___________ End Date:____________
****************************************************************************************
Medical School Diploma or Medical School Transcript with a letter of completion sealed from the Medical
School:_________________________________________________ Graduation Date:_________
(Attachment D)
If Applicable:
ECFMG Certification #:___________________ ECFMG Certification Date:________________________
(Attachment D– if applicable)
________________________________________________
Resident/Fellow Signature
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Date:_____________________
Visiting Resident/Fellow Rotation
Page 6
Section II. To be completed by the applicant’s current Residency/Fellowship Program Director:
1.
The resident/fellow named above is in good standing and currently a member of the <<Visiting
Resident/Fellow’s Current Program Name>> residency/fellowship program.
2.
On the dates requested for rotation, the resident/fellow is a <<PGY Level>> resident/fellow.
3.
An evaluation _______ will _______will not be requested at the end of the elective rotation.
4. Background Checks:
The << Visiting Resident/Fellow’s current Sponsoring Institution Name>> will check the following
databases prior to placing a resident/fellow at KUMC for a clinical rotation:
Kansas Highway Patrol Criminal Background Check
Other State Criminal Background check (previous residences other than KS in the past
seven years) Office of the Inspector General
Kansas Sex Offender Registry
Other State or National Sex Offender List (previous residences other than KS in the past
seven years)
Name, Social Security Number and Address Verification
In cases where the background investigation was not conducted previously, the investigation will then be
conducted prior to the start of the clinical rotation.
KUMC will not accept residents/fellows for clinical rotations if their background information revealed any
convictions for any crime against persons; robbery in the first degree; pharmacy robbery or arson in the
first or second degrees; felony crimes related to drugs and alcohol; or any other crime that would not permit
an individual to be licensed or registered by their profession upon completion of the educational program.
It is the responsibility of <<Visiting Resident/Fellow’s current Sponsoring Institution Name>> to review
the background information prior to the resident/fellow coming to the Hospital and Sponsoring Institution
will not send any resident/fellow whose background information does not meet the standards defined in this
paragraph.
5. The resident/fellow has our approval to take this elective, and their background check has been completed,
reviewed and fulfilled state requirements.
_______________________________________________________________
Residency/Fellowship Current Program Director (Print)
_______________________________________________________________
Residency/Fellowship Current Program Director (Signature)
_______________________________________________________________
Sponsoring Institution Name
______________________
Date
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Section III. To be completed by an official of the <<Visiting Resident/Fellow’s current Sponsoring Institution
Name>> in whose program the resident/fellow is currently a member:
1. Personal health coverage is in effect while the resident/fellow is away from our program.
2.
KU Hospital HIPAA Confidentiality Policy Compliance is in effect for this resident/fellow. (Attachment F)
3.
Malpractice insurance is extended to cover resident/fellow while the resident/fellow is on this elective rotation.
4. The resident/fellow has our approval to take this elective.
___________________________________________
DIO of Sponsoring Institution (print)
____________________________________________
Name of Sponsor
____________________________________________ ___________________________________________
DIO of Sponsoring Institution (signature)
Mailing Address
____________________________________________ ___________________________________________
Title
City, State, Zip Code
___________________________________________ ____________________________________________
Date
Telephone Number
Section IV. To be completed by the University of Kansas Medical Center Residency/Fellowship Program
Director:
The resident/fellow has my approval for the visiting rotation.
KUMC Program:__________________________
________________________________________________
Residency/Fellowship KU Program Director (Print)
________________________________________________
Residency/Fellowship KU Program Director (Signature)
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Date:_____________________
Visiting Resident/Fellow Rotation
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ATTACHMENT A
<<Training Site>>
Rotation Schedule and Goals and Objectives
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ATTACHMENT B– part 1
<<Training Site>>
Temporary or Permanent Kansas License Certificate
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ATTACHMENT B– part 2
<<Training Site>>
If rotating in Missouri Hospital Site while visiting KU,
Missouri License Certificate
\
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ATTACHMENT C– part 1
<<Training Site>>
Kansas DEA
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ATTACHMENT C– part 2
<<Training Site>>
Missouri BNDD (If Applicable)
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ATTACHMENT D
<<Training Site>>
Medical School Diploma or
Medical School Transcript with a letter of completion sealed from the Medical
School or the ECFMG report
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ATTACHMENT E
KU Health Information Registration
(REGISTRATION INFORMATION CHECKLIST)
Name of student/trainee:______________________________ SSN: ___________________
Sponsoring Dept./Div.: _______________________________
Contact:_________________________
Phone:_____________
Parent Institution:____________________________________
Contact:_________________________
Phone:_____________
University of Kansas Medical Center
Registration Policy for Students or Trainees
Every person participating in any education or training program at the University of Kansas Medical Center must be
registered by the appropriate office on campus. Because of the unique mission of our institution, we have an
obligation to protect patients, employees, and visitors who come in contact with people engaged in education or
training programs. It is important that information about Medical Center policies and procedures be provided. Visiting
students/trainees will be held to the same standards to which we hold our own students, employees, faculty and staff.
COVERED STUDENTS/TRAINEES:
All students, clinical or non-clinical trainees, and visitors or observers of clinical practices or procedures must comply
with the registration policy whether or not university credit or certification is granted.
DEPARTMENTS/DIVISIONS RESPONSIBLE FOR REGISTRATION:
Student Records and Registration: Every person participating in a program or course awarding academic credit
or leading to a degree, diploma, or certificate from the University will register with the Director of Student
Records and Registration.
Clinical/Academic Department: Every person not registered with either of the above two offices will be registered
by the clinical or academic department approving the student/trainee’s presence at the University of Kansas
Medical Center. This would include but is not limited to clinical trainees performing externships or clerkships,
guest faculty/staff, or other visitors invited to observe or participate in any aspect of patient care.
The department will ensure completion of the Registration Information Checklist (Appendix A) on each
student/trainee. The checklist must be completed prior to the beginning of training. The checklist is the minimum
information required; therefore, the sponsoring department may request more information as deemed appropriate in
the individual situation. The student/trainee should carry a completed copy of the checklist with them in case
emergency medical services are required.
COMMUNICABLE DISEASES / IMMUNIZATIONS / TESTS
University of Kansas Medical Center requires that the student/trainee be free of any communicable diseases that may
be transmitted to fellow students, patients or employees. Details of required immunization status for Tuberculosis,
tetanus, Rubeola (measles), mumps, rubella, chickenpox and hepatitis B are found in Appendix A. Depending on the
immunization status of the student/trainee, the student/trainee may be given the appropriate immunizations by
Student Health or Occupational Health provided arrangements for payment are made or provided by their primary
care physician. If the student/trainee chooses to decline an immunization that is recommended, they must do so in
writing. Copies of the declinations can be signed in Occupational Health and will be kept with the student/trainee’s
paperwork in the Graduate Medical Education (GME) office.
USE OF UNIVERSITY OF KANSAS MEDICAL CENTER FACILITIES AND SERVICES:
Personal health care services may be provided by KUMC practitioners under guidelines and restrictions as identified
in the individual student/trainee’s personal medical insurance policy.
Visiting students/trainees not eligible to be seen in Student Health and requiring preventive services (immunizations,
PPD, etc.) or care for work-related injuries/exposures (occurring while on campus in the course of performing their
duties) may be seen in the Occupational Health Clinic during normal working hours or in the Emergency Department
after normal working hours, providing payment is guaranteed by the parent institution, sponsoring department or
visiting student/trainee.
RECORDKEEPING
All completed checklists for students/trainees will be kept in a confidential file in the GME office. No services will be
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provided without a completed checklist.
ENFORCEMENT
The checklist must be completed prior to matriculation. If the checklist is not completed, the prospective
student/trainee will be returned to their parent institution and will not be allowed to begin training.
IMMUNIZATION & TB STATUS
You will have to schedule an appointment with the University of Kansas Medical Center Occupational Health Clinic.
You may schedule this by calling 913-588-6512. Please bring documentation of the following with you to the
appointment; including all dates and titer results!
-BRING THE FOLLOWING DOCUMENTATION TO YOUR
SCHEDULED APPOINTMENT WITH OCCUPATIONAL HEALTHImmunization or Test
DPT (Diphtheria, Pertussis,Ttetanus): Two 0.5 ml doses IM (deltoid) 4 weeks apart; third dose 6-12 months after second
dose. Booster every 10 years or after 5 years for wound management.
Tdap (Tetanus, Diphtheria and Pertussis) Routine: single dose to replace Td booster ≥10 years earlier. Shorter Interval:
> 2 years since last Td booster and care for infants < 12 months old.
MEASLES (Rubeola): documentation of adequate vaccination (2 doses MMR at least 1 month apart, at or after 12 months
of age) or laboratory evidence of immunity to measles.
MUMPS: documentation of adequate vaccination (2 doses MMR at least 1 month apart, at or after 12 months of age) or
laboratory evidence of immunity to mumps.
RUBELLA (German Measles): documentation of adequate vaccination (2 doses MMR at least 1 month apart, at or after 12
months of age) or laboratory evidence of immunity to rubella.
HEPATITIS B: Two 1.0 ml doses IM (deltoid) 4 weeks apart; third dose 5 months after second) and positive titer/screen.
CHICKEN POX (Varicella): documentation of adequate vaccination (Two 0.5 ml. doses SC 4-8 weeks apart) or laboratory
evidence of immunity.
TUBERCULOSIS: A two-step PPD testing protocol is followed. KUMC will place one at the time of your visit. You will need
to bring documentation of another one within 12 months preceding. If history of a positive PPD test, documentation of a
negative chest x-ray within the past 12 months, a negative TB symptoms questionnaire, and description of any postconversion treatment is required. Documentation needs to include the below info but you cannot fill this out and call it
documentation we need the note from where it was done.
Last PPD Skin Test less than 12 months old:
If you had a positive TB skin test was a chest X-Ray completed?
If “Yes”: Date of chest x-ray: ______________
□Yes
Results: ___________________________
Have you ever taken medication for a positive TB skin test?
If “Yes”: Name of Medication:
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□No
□Yes
□No
Length of treatment:
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ATTACHMENT F
Hospital O2 Computer Access Resident/Fellow Request Form
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ATTACHMENT G
The University of Kansas Hospital Authority
CONFIDENTIALITY AGREEMENT/SIGNATURE ATTESTATION
READ CAREFULLY – The University of Kansas Hospital Authority is committed to protecting the privacy and
security of individually identifiable health information, organizational, and other information of a confidential nature
for the hospital organization and its affiliates (collectively known as “confidential information”). As a system user
you hold a position of trust. Information pertaining to patients, confidential information, and other sensitive
information must be held in strict confidence.
All system users at the University of Kansas Hospital are required to read the following agreement and agree to
comply with this Agreement by signing where indicated.
1. I understand that my computer sign-on is my own individual, personal code for gaining access into University of
Kansas Hospital Authority Computer Systems (e.g. SMS, Centricity, Logician, PACS, Tracemaster, etc.) and I agree
that I will not share my login ID and/or password with anyone.
2. My computer sign-on allows me to access only such information which I have been authorized to use to perform
my job responsibilities and I agree that I will only use my computer access as appropriate in order to carry out my
assigned duties.
3. I understand that my computer sign-on and my electronic signature or initials, if applicable, act as my personal
signature, as if I had signed a paper document, when performing all computer activities and is legally binding as my
authorized personal signature.
4. I understand that the information I access through hospital systems is privileged, and/or confidential, and is to be
used only in the performance of job-related or patient-related activities. I agree that I will not divulge confidential
information unless requested to do so by my supervisor or other authorized personnel in the performance of my job
duties or as required by law.
5. I understand that it is a violation of the University of Kansas Hospital’s Medical Record Ownership and
Accessibility Policy to print any confidential information remotely (for example, home, hotel, or any off-site
printer). I agree not to print confidential information remotely.
6. I am responsible for notifying my Human Resources department should I undergo a name change. That way the
sign-on will be kept accurate at all times. I will also notify HIPAA Commitment at extension 5-5490 if I have reason
to believe there may be a breach of confidentiality and/or I have reason to believe someone has accessed and/or is
using my or any other person’s password so that the appropriate action may be taken.
7. I must sign off of a computer system if I leave the computer terminal for any period of time. I understand that
failure to sign off of a Hospital computer system is a violation of the University of Kansas Hospital Authority’s
confidentiality and patient privacy policies. I am responsible for all information accessed with my sign-on.
8. Any user (i.e. employee, staff, student or volunteer), or vendor employee (i.e. Business Associate), viewing
patient information in the course of their job duties must agree to maintain the confidentiality of this information. In
addition, I agree that no medical record is to be removed from the KUMC campus.
I have read this agreement and by signing below I agree to comply with the policies as stated. I understand if I share
my sign-on, use someone else’s sign-on, or fail to comply with this Agreement or any of the Hospital’s
confidentiality or patient privacy policies, I will be committing a breach of hospital policy. I understand that I must
not disclose confidential information, except, as such disclosure is part of the performance of job duties. I further
understand that inappropriate disclosure and/or access of confidential information or any breach of University of
Kansas Hospital Authority confidentiality and privacy policies will result in disciplinary action including possible
loss of access to Hospital Computer Systems and possible termination. My agreement to the above shall continue
even after I leave association with the Hospital or its affiliates.
User’s Signature:_______________________________________________Date:__________________
User’s Name & Title (Print):____________________________________Dept:____________________
Organization (please circle 1):
MAC / MATCS / Jayhawk / Med Center / KUPI / KU Hospital Authority/Other____________
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ATTACHMENT H
KU School of Medicine HIPAA
CONFIDENTIALITY POLICY
VISITING FELLOWS, RESIDENTS, STUDENTS
Patients at KU Medical Center are entitled to confidentiality with regard to their medical and personal
information. The right to confidentiality of medical information is protected by state law and by federal privacy
regulations known as the Health Insurance Portability and Accountability Act (“HIPAA”). Those regulations
specify substantial penalties for breach of patient confidentiality.
1. All patient medical and personal information is confidential information regardless of the
educational or clinical setting(s) and must be held in strict confidence. This confidential
information must not become casual conversation anywhere in or out of a hospital, clinic
or any other venue. Information may only be shared with health care providers,
supervising faculty, hospital or clinic employees, and students involved in the care of or
services to the patient or involved in approved research projects, who have a valid need to
know the information.
2. Under strict circumstances, upon receipt of a properly executed medical authorization by
the patient or a HIPAA-compliant subpoena, medical information may be released to the
requesting party. Inquiries regarding the appropriateness of the authorization or
subpoena should be directed to the medical records department or the University’s Office
of Legal Counsel at 913-588-7281, depending upon the situation.
3. Computer user codes/passwords are confidential. Only the individual to whom the
code/password is issued should know the code. No one may attempt to obtain access
through the computer system to information to which he/she is not authorized to view or
receive
4. If a violation of this policy occurs or is suspected, immediately report this information to
your supervising faculty.
5. Violations of this policy will result in disciplinary action up to and including termination
from the program. Intentional misuse of protected health information could also subject
an individual to civil and criminal penalties.
I, ________________________________, acknowledge receipt of this Confidentiality Policy. I have read the
policy and agree to abide by its terms and requirements throughout my education/training at K.U. Medical Center
and as part of my participation in patient care activities.
Signature_________________________________________ Date ________
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ATTACHMENT I
<<Training Site>>
HIPAA Certificate of Training- from home institution
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ATTACHMENT J
<<Training Site>>
National Provider Information Number
Revised 3/14/2013
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ATTACHMENT K
<<Training Site>>
Proof of Malpractice Insurance/Certificate ($1,000,000/$3,000,000)
Revised 3/14/2013
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Visiting Resident/Fellow Rotation
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ATTACHMENT L
Visiting Resident/Fellow Clearing Form
INSTRUCTIONS: Obtain the signatures of the departments or individuals listed below. Return this
form to your Residency Coordinator by the last day of training. The Residency Coordinator is to
provide the Graduate Medical Education Office with a copy prior to the completion of your visit.
Clearance Item
Signature
Archie Dykes Library-Fines or Outstanding Materials
Front Desk
Identification Badge Turn-In
Human Resources
Additional Affiliates:
Keys (Department)
Program Coordinator
Additional Affiliates:
Medical Records-KU Hospital
Additional Affiliates:
Medical Records-UKP
Additional Affiliates:
Pager--TURN OFF VOICEMAIL FORWARDING
Program Coordinator
Parking Services
Support Services Facility, 2100 W. 36th Ave
Duty Hours Logging Complete in E*Value
Program Coordinator
Provide Program with New Address
Program Coordinator
Meal Card - KU Hospital
Program Coordinator
Revised 3/14/2013
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