DHIP Provider Offboarding NotificationAdmin. staff use only

DHIP Provider Offboarding Notification

Admin. staff use only

This form serves as official notice of a pending departure or termination. Complete this no later than 90 days prior to the provider's departure date.

If you've submitted a notice of provider leaving and they decide to STAY - please inform rebecca.gill@duke.edu (don't submit another form).

Notice Requirements: Physicians must give 6 months and APPs must give 3 months. Policy is that providers should have their last week with NO patient contact so they can wrap up administrative work. (Exception: Anesthesiologists who do ONLY OR work- can work in OR up to their last day.)

*Do NOT submit this form for Fellows.

If you need assistance with this form, please contact: rebecca.gill@duke.edu or the DHIP Clinician Service Center at DHIPservicecenter@duke.edu.

BENEFITS/PAYROLL QUESTIONS:

DHIP or SOM faculty dhipbenefits@duke.edu, 919-613-3447.

Payroll: 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 change to adjunct/PRN /academic*

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

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*

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse