DHIP Clinician Offboarding NotificationDepartmental Submission Required for Clinician SeparationsFor Administrative Staff Use OnlyThis form must be completed by designated representative

DHIP Clinician Offboarding Notification

Departmental Submission Required for Clinician Separations

For Administrative Staff Use Only

This form must be completed by designated representative

This form serves as the official notice of a pending departure or termination of a DHIP-affiliated clinician. To ensure timely processing and minimize administrative delays, this form must be completed no later than 90 to 180 days in advance of the anticipated departure date.

IMPORTANT: If a previously submitted departure notice is no longer applicable because the clinician has decided to remain with DHIP, do not submit a new form. Instead, promptly notify the DHIP Clinician Service Center via email at DHIPServiceCenter@duke.edu.

Clinician Notification Expectations:

To maintain compliance with payroll and transition protocols:

Physicians are expected to provide six (6) months’ notice
Advanced Practice Providers (APPs) are expected to provide three (3) months’ notice

Failure to adhere to these guidelines may result in processing delays or overpayment issues.

Note: This form should not be submitted for Fellows.

Need Assistance?

For support or guidance while completing this form, please contact the DHIP Clinician Service Center at DHIPServiceCenter@duke.edu.

Thank you for your attention to this process and your continued partnership.

DHIP Benefits or Payroll Question?

cDHIP or Dual-Funded Faculty: Email dhipbenefits@duke.edu or call (919) 613-3447.
Payroll: Email DHIPservicecenter@duke.edu

Submitter Name (First and Last)*

Submitter email*

Name of Resigning Physician/APP (First and Last)*

**Do Not submit this form for Fellows, we do not Offboard them.

Duke ID of provider*

Net ID of provider*

Duke email*

DHIP Affiliation*

This helps us determine who they receive pay from & who should terminate them - DHIP Service Center or the SOM department.

**IF NOT DHIP AFFILIATED, DO NOT SUBMIT THIS FORM.**

Select or enter value

Degree - select from list*

Select or enter value

** Leaving Duke or appointment change*

Select or enter value

If transferring departments within Duke, check this box and submit written details as an attachment with details.

Faculty Title (if applicable)*

Select or enter value

Do they have an APP listed on their license that they supervise?*

Yes

Please list APP name(s)*

APP -list supervising/collaborating physician*

Department - select from list*

Select or enter value

Division - select from list*

Select or enter value

Clinical Setting - select one*

Ambulatory

Inpatient

Both

Is this a C-DHIP provider?*

Select or enter value

HCA - or practice manager's name*

Clinical Vice Chair - add in notes if not on list*

Select or enter value

Last Clinical Date*

DHIP Policy is 5 days admin time needed to wrap up work without pt. contact. Clinic/Div. leadership can waive/modify to 3 days or less. Auto waived for Anesthesiology OR providers.

Last Day at Duke*

Has an Exit Interview been offered. If no, why not*

The dept is responsible for managing/tracking/reporting on these

Bill Area - (if known)

Facilities where privileges need to be removed*

Select all that apply

Select or enter value

cFTE - list percentage*

Please enter as 0.8, not 80%

Personal Email (DHIP needs for W2 tax form )*

Total Years of Duke Service*

Enter as a number only please - 5.5, not 5 years 6 months.

Is provider a member of a UREF* faculty class?*

Select or enter value

Primary reason for departure:*

Select or enter value

If other, please explain

Secondary reason for departure (if applicable):

Select or enter value

Clinical Location & Main Clinic Phone Number*

NPI #*

Covering provider for inbasket/patient results (results will be directed to this person)*

I have notified the covering provider above of this provider's departure*

Yes

Please upload your resignation letter and Chair to Dean Letter (where applicable)

The letter must include whether or not the provider is leaving Duke entirely (vs. adjunct or research role). This provider notification form will be shared with your applicable leadership.

File Upload*

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