Form Med - Acceptance Of Responsibility By Alaska Facility, Hospital, Clinic - Alaska Department Of Community And Economic Development

ADVERTISEMENT

ALASKA STATE MEDICAL BOARD
MED
Department of Community and Economic Development
For Office Use Only
Division of Occupational Licensing
(333 Willoughby Avenue - Ninth Floor)
Post Office Box 110806, Juneau Alaska 99811-0806
(907) 465-2541
E-Mail: license@dced.state.ak.us
ACCEPTANCE OF RESPONSIBILITY
by
ALASKA FACILITY, HOSPITAL, CLINIC
Instructions to the Resident Applicant:
Complete the information in Parts I and II below. Type or print legibly. Mail the
form to the Alaska facility, hospital, or clinic where you intend to serve your
residency rotation.
PART I
RESIDENT APPLICANT
Name:
Last, First, Middle (Maiden or Other Names Used)
Date of Birth (M/D/Yr)
MD
DO
PART II
RESIDENCY PROGRAM
Name of Program
Address
Program Telephone
City, State, Zip
(Applicant: Do Not Write Below This Line. Do Not Detach.)
Instructions to the Alaska Facility:
Please complete Part III below, sign Part IV, and return this document directly to the
board at the letterhead address.
PART III
ROTATION AUTHORIZED FOR
Name of Alaska Facility, Hospital, Clinic
Location
Dates of Rotation:
From:
To:
Physician Primarily
Responsible for
Printed
Training/Supervision:
Name ________________________________
Signature _________________________________ Date____________
PART IV
VERTIFICATION OF ACCEPTANCE OF RESPONSIBILITY
I CERTIFY THAT the Resident Physician named above has been accepted by this institution to serve as a resident. This
physician will be serving a portion of his/her clinical training at the Alaska institution named above. This institution accepts
responsibility for this physician’s training and supervision while he/she is located at this institution.
_________________________________________________________
________________________________________________________
Signature, Physician Clinical Director
Date
Printed Name
Title
08-4022 d (Rev 09/2000)
ALASKA STATE MEDICAL BOARD
MED

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go