(Note: Required Fields are Red)

1. New Address For W2’s, Certificate(s), etc (please make sure your PROGRAM COORDINATOR has your NEW ADDRESS INFORMATION):

Street Address:
City:
State:
Zip Code:
Phone #:
Email Address:

2. If you are pursuing additional training, please complete the following:

a. Specialty: b. Institution:

3. If you are completing your training and entering the work force, please complete the following:

a. Please check the type of position that best describes your new job:

Standing Faculty
Instructor
Adjunct Faculty
No Faculty Appointment

b. Please check the type of practice that best describes your new job:

Hospital-based Group
Multi-disciplinary Group
Solo Practice
Single-specialty Group
No practice

B. Trainee Benefits:

• If you are continuing your employment at UPHS, please skip to bottom of page and submit your information.
• If you are terminating your employment at UPHS, please note the following with respect to benefits:
• Health and Dental Benefits will end on the last day of the month you terminate (Ex. Last day is 6/19/10 – benefits will end on 6/30/10)
• If you have questions about Disability Insurance contact the InsMed Insurance Agency at 800-214-7039.
  COBRA:
• Under Federal law, SHPS will notify you within 44 days of your rights to continue group health, dental and/or vision coverage for up to 18 months after the date of termination.
• If COBRA coverage is needed, the GME Office needs your forwarding address by the first day of your termination month.
• You have 60 days from the Date of Termination to elect or reject continuation of group health and/or dental coverage.
• If continuation is elected, the premium must be paid directly to SHPS within 45 days of continuation election.
• Questions about COBRA - contact the UPHS Corporate Customer Service Department at 215-615-2277/ option 1

• Meet with the Program Director
  
• Complete the Following for GME:
  
  • Complete the annual GME Survey
    
  • Return GME issued items (pager, ID badge, parking swipe card and decal) to your Program Coordinator

Submission of this form acknowledges your review and understanding of the contents.