Diversity Information Page 16
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26HENRY FORD HOSPITAL
GRADUATE MEDICAL EDUCATION
ACCESS REQUEST FORM INSTRUCTIONS
Please complete ONLY the following on the Access Request Form:
PAGE ONE:
1.
Name
2.
US Social Security Number (leave blank if you do not have one)
3.
Ethnicity (required for patient electronic record system)
4.
Date of Birth
5.
Indicate Female or Male
6.
Job Title (indicate Resident or Fellow)
7.
Primary Department (name of your training program)
8.
Metavision Role (indicate Resident or Fellow)
9.
If you are transferring from another Henry Ford Health System hospital,
please specify your current hospital and include the start date as indicated on
your contract in the line “If transfer. . .”
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