Rev. 11/30/2017
MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS, INC.
NON-MCWAH HOUSESTAFF ASSIGNMENT FORM
Listed below is the form that is used to report assignments of Non-MCWAH housestaff to MCWAH institutions. The purpose of the form is to notify the administrator
of the receiving hospital of the arrangements for professional liability coverage. This form is also used by the receiving hospital to claim Medicare reimbursement. A
MCWAH housestaff time record must be completed and returned to the MCWAH Office at the conclusion of the rotation. The Confidentiality Agreement, Background
Information Disclosure (BID) form and Consumer Authorization form must also be completed. Any changes to information provided on the Background Information
Disclosure form must be reported to MCWAH or the MCWAH Program Director for your rotation within 24 hours. The resident must also attach a certificate of
professional liability insurance, documentation of health requirements and proof of OSHA Bloodborne Pathogen Training compliance. This form should be signed by
the resident’s Program Director and the MCWAH Program Director. This form (and accompanying forms) should be sent to the MCWAH Office at least 3 months
prior to the rotation.
Non-MCWAH residents and fellows must have either a current Wisconsin Resident Educational License (REL) or a full and unrestricted current Wisconsin Medical
License. A copy of the license must be provided to MCWAH as part of the rotation approval process. Information about each of these licenses can be obtained by
the Wisconsin Department of Safety and Professional Services
.
MCWAH will assign a five-digit number to the resident and report that number back to the Program. The resident must use that number after his/her signature when
making chart entries at CHW, FMLH or ZVAMC.
SECTION 1 To Be Completed by the Applicant.
Resident Name Social Security #
Current Address
Phone Number Email
Medical School Graduation Date
If IMG, ECFMG # Certificate Date Date of Birth
Dates of MCWAH Rotation to MCWAH Program
NPI # DEA #:
WI REL # WI License # (if applicable)
Please list all of your current and previous GME Training in the United States:
Name of Facility Program PG Level(s)
Dates of Training to
Name of Facility Program PG Level(s)
Dates of Training to
Additional Info/Training
Signature of Resident/Fellow Date
SECTION 2 To Be Completed by the Applicant’s Program Director.
I request approval for the above resident to function in your institution for the period noted. I have reviewed his/her credentials and certify them as acceptable.
Our hospital will not claim Medicare reimbursement for this rotation. Our home institution will provide the resident with primary professional liability insurance (PLI)
for the resident for this rotation in the amount of $1 million per occurrence and $3 million in aggregate and excess professional liability coverage in the amount of
$5 million. In addition, if the professional liability coverage is a claims-made policy, the resident’s home institution agrees to provide an extending reporting period
or “tail” for the resident at the time the resident terminates or leaves his or her training program.
Submit the following:
Malpractice Insurance – PLI Certificate Attached Background Information Disclosure w/Consumer Authorization Form
MCWAH Confidentiality Privacy Form CHW Compliance Training Post Test
HIPAA Training Post Test
Froedtert Network Access (For rotations to Froedtert Health Entities Only)
EPIC Access for Clinical Documentation EPIC Read Only Access
Other applications access needed (please specify):
Healthcare Information - Attach Documentation to Verify
TB Testing (within last 90 days) Mumps Antibody Titer or 2 MMR vaccinations
Measles Antibody Titer or 2 MMR Vaccinations Positive Antibody Titer or 2 Documented Varicella Vaccinations
Rubella Antibody Titer or 1 MMR Vaccination Bloodborne Pathogen Training
Hepatitis B Vaccine Series or Positive HBSAB Titer Flu shot (only if rotation is between November 1 and April 1)
Signature of Resident’s Program Director Date
SECTION 3 To Be Completed by MCWAH Program.
Program Hospital of Rotation: FMLH CHW VAMC Other
MCWAH Program Director’s Signature Date
MCWAH ID # Assigned ___________
Please PRINT
and complete page 1
