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2014 Graduate Medical Education Release Form

(Note: Required Fields are Red)

Trainee’s Name:
Termination Date:

Department:

Program:
A. Trainee Future Plans:

1. New Address For W2ís, 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:




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
Malpractice Insurance:
Please note that your malpractice insurance terminates on your separation date. You will have no coverage until your new employment begins.

I understand that I am expected to take the following actions in connection with my resignation:
  • 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.

 


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