Card Services Medical Center Authorization Form
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1Medical Center Authorization Form
Office Location: Medical Center North‐ S2311
Office Hours:
Monday – Friday
Phone:
615‐936‐3350; 615‐936‐7026
8:30am ‐4:30pm
Fax:
615‐936‐3351
Closed daily: 1:00pm ‐2:00pm
Reason for Card
New Hire
Status Change
Damaged
Lost ($20.00 Fee & NEW Photo)
VU Student
Other
*Birth Date:
________________________
*(Please DO NOT fax or email Birth Date information)
Legal Name: First ____________________________ Middle ___________________ Last ______________________________
Preferred Name on Card: __________________________________________________________________________________
Department:
___________________________________________________________________________________________
Job Title:
___________________________________________________________________________________________
Credentials:
______________________________________________________________ (limit 3)
Design Your Card
(Please check only one)
Which Logo:
VUMC
VCH
Does the card need a magnetic stripe: Yes
No
Do you need a duplicate Card:
Yes
No
(for Clinical Staff only)
Are you an Infant Handler (pink) : Yes
Department Authorized signature REQUIRED
________________________________________________________
Contact # _____________________
STATUS
(Please check only one)
Staff/Faculty/Student:
Card Color:
OTHER:
Expiration date:
Regular Staff/Faculty
White
(900)
Affiliate/Contractor
____________
Vanderbilt Temporary Service
White
(840)
Visitor
____________
Vanderbilt Student
White
(990)
Volunteer ____________
(940)
Student‐Special Program ____________
(850)
Veteran’s Admin
____________
Clinical Affiliate/Visitor:
Expiration date:
Clinical Staff:
Card Color:
Registered Nurse‐RN
Light Blue
(910) Registered Nurse‐RN ____________
Licensed Practical Nurse‐LPN
Titan Blue
(910) Licensed Practical Nurse‐LPN ____________
Nurse Practitioner/CRNA/PA
Dark Blue
(910) Nurse Practitioner/CRNA/PA
____________
Clinical Fellow/Resident Physician
Light Green
(920) Visiting Clin Fellow/Resident Physician ____________
(920) Clinical Physician‐MD ____________
Clinical Physician‐MD
Dark Green
Respiratory
Gold
Paramedic
Red
CARD HOLDER Signature: ____________________________Print Name __________________________Date _________
DEPT Authorized Signature: __________________________Print Name ______________________________Ext# _______
The ID Card(s) received above are the property of Vanderbilt University and must be returned to University officials upon request or separation from the University
Office USE ONLY PIK #___________________________________________
Revised 7/2014
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Parent category: Medical