Ambulatory Schedule Change Form
Physician __________________ Division _______________ Today’s Date ______ Clinic Location ___________
AMBULATORY SESSION(S) TO BE CANCELLED, Do not enter patients’ names (Use back side if needed)
DATE
TIME: __ - __
# PATIENTS SCHEDULED
[INDICATE # NEW(N) & # RETURN (R)]
DATE
TIME: __ - __
# PATIENTS SCHEDULED
[INDICATE # NEW(N) & # RETURN (R)]
1. Reason for ambulatory session cancellation (check one).


Annual Leave. 1-month notice. The Department encourages more advance notice whenever possible.
Maternity/Paternity Leave. 1-month notice is expected, if possible. Physicians are encouraged to notify
scheduling staffers not to appoint patients to ambulatory sessions during periods of anticipated
maternity/paternity leave.

Sick/Family Medical Leave. Notice is expected at time of illness. The Department strongly encourages
notice 1 month before anticipated sick leave, such as elective surgery.

Inpatient Attending/Consult Responsibilities. Notice is required no later than July 1 of the academic
year. New ambulatory session hours should be opened during the attending months to equal the number
of ambulatory session hours closed, if possible.

Academic or Administrative Responsibilities. 1 months notice. Exceptions to the 1 months notice will
be made with consideration given to the importance of the activity to the Department of Medicine; the
number of previous exceptions granted to the physician; and the date the physician became aware of the
scheduling conflict. New ambulatory session hours should be opened to equal those closed.
Please make any comments here about special circumstances:
_______________________________________________________________________________
2. Ambulatory Session Openings (check one)




No ambulatory sessions will be opened because cancellations were due to annual leave,
maternity/paternity leave, or sick/family medical leave or because Division Director approves not
opening more sessions.
New ambulatory session(s) will be opened by physician cancelling session. (Note date/hour(s) below)
Cancelled session hour(s) will be covered by _____________________. (Patients do not have to be
rescheduled.)
(colleague’s name)
Different session hour(s) will be opened by _____________________ to accomodate rescheduling of
patients. (Note date/hour(s) below.)
(colleague’s name)
DATE
TIME: ___ TO ___
Check one:
DATE
TIME: ____ TO ____
hrs. opened > # hrs. cancelled
__________________________
Requesting Physician
DATE
TIME: ____ TO ____
hrs. opened < # hrs. cancelled
_______________________________
Division Director
____________________________
Department Chairman
For Office Use Only
Date cancellation notification received ___________ Date Approved ___________
Schedulers notified by: ___________ Date _____________
All patients rescheduled by ________________ Schedulers faxed completed form to physician ___________
(date)
(date)
Effective 6/7/99
Revised 10/20/99