Forms and Notices

Housestaff

Policies and Guidelines

UCSD Medical Center Terms and Conditions of Appointment Document - [668 kb]

House Officer Policy and Procedure Document - [13 kb]

Licensure and Registration

Request for Examination and Board Action History Report (EBHAR) ( ONLINE FORM   |  PAPER FORM )

USMLE Step 3 Registration ( ONLINE FORM   |  PAPER FORM )

New Residents

1. State Oath of Allegiance and Patent Agreement, UPAY585 (R11/97) - [34 kb]
2. Application - [836 kb]
3. Dean's Report - [518 kb]
4. Report of Performance - [522 kb]
5. Acknowledgement of Child Abuse Reporting & Elder/Dependent Adult Abuse Report form - [75 kb]
6. W-4 - [792 kb]
7. W-4 - Nonresident Alien - [532 kb]
8. Payroll Wage Distribution Request - [54 kb]
9. Statement Concerning Your Employment in a University Position Not Covered by Social Security - [32 kb]
10. Employment Eligibility Verification form I-9 - [960 kb]
11. Certificate of Foreign Status for Federal Tax Withholding - [6506 kb]

Visiting Residents

1. Biographical Data
2. UCSD Resident/Fellow Position Description
3. HIPAA Memorandum
4. Information Security Awareness Information Sheet
5. Acknowledgement of HIPAA Training
6. HIPAA Confidentiality Agreement
7. California Medical License Registration Form - Non-Navy Applicant - [37 kb]
8. California Medical License Registration Form - Navy Applicant
9. UCSDs Standards of Business Conduct Acknowledgement Form - [1560 kb]

HIPAA

HIPAA Memorandum

Information Security Awareness Information Sheet

HIPAA Confidentiality Agreement

Acknowledgement of HIPAA Training

UCSD Minimum Security Standards - [20 kb]

Benefits

Active Trainees

For Your Benefit handbook - [276 kb]

Rotating Liability Request Form

Moonlighting Liability Request Form

Blue Cross Enrollment Form - [166 kb]

Blue Cross Change Form - [75 kb]

Blue Cross Affidavit of Domestic Partnership

Standard Insurance Enrollment and Change Form

Vision Services Plan Enrollment Form

COBRA

Notice of Right to Elect Continued Health Coverage

Summary of COBRA Insurance Continuation

Blue Cross COBRA Enrollment Form - [170 kb]

COBRA Standard Dental Enrollment Form

Vision Services Plan Enrollment Form

Standard Life Insurance Group Conversion Packet

Standard Group Conversion Request for Long Term Disability Insurance

Notice to Terminating Employees

Important Notice Regarding COBRA Coverage

Program Directors

Sample Template for Departmental/Program Use - [26 kb]

Program Coordinators

Affiliate Reimbursement Billing Form - [19 kb]

State Oath of Allegiance and Patent Agreement, UPAY585 (R11/97) - [34 kb]

Acknowledgement of Child Abuse Reporting & Elder/Dependent Adult Abuse Report form - [75 kb]

Employment Eligibility Verification form I-9 - [960 kb]

Academic Biography - [57 kb]

Certificate Request Form - [23 kb]

Sample Meal Request Form - [27 kb]

Monthly Summary Sheet

Program Letter of Agreement Template  - [24kb]

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