Visiting Resident Rotation Request

Visiting Resident Rotation Request

PLEASE REVIEW THE FOLLOWING INFORMATION PRIOR TO COMPLETING THIS FORM.

This form must be submitted six months prior to the desired rotation start date.
Before completing this form please be sure to fill out the attached Authorization Form and obtain a Program Letter of Agreement (PLA) with the receiving Ascension / Dell Med Program Director's or Sponsoring Physician's Signatures. You will be required to upload these documents at the bottom of this form.
A visiting rotator must be a U.S. Citizen, Permanent Resident, or J-1 Visa Holder already within the United States in order to be eligible to rotate.
Any outside rotators must contact the Texas Medical Board (TMB) for instructions on obtaining a Rotator Physician in Training Permit (PIT). Please contact TMB at pits@tmb.state.tx.us.
It is the responsibility of the Visiting Resident to make sure the Ascension / Dell Med Program Coordinator and Program Director are aware of this rotation ahead of time and have authorized this rotation.

Desired Rotation Start Date*

Must be at least six months from date of submission.

Desired Rotation End Date*

First Name*

Last Name*

Degree*

PGY Level*

Select

Military

Please select if you are military

Specialty*

Please select the specialty you will be rotating with

Select or enter value

Other Specialty*

Trainee's Email Address*

Trainee's Phone Number*

Have you Rotated through Ascension/Dell Med before?

Please check if you have rotated with us before

Home Institution*

Please select your institution if it is contained within the dropdown, if not select other and enter your Home Institution

Select or enter value

Other Institution*

Rotation Site*

Select or enter value

Other Site*

Are you a US Citizen*

Yes

If not a US Citizen, what is your status?*

Select or enter value

Home Institution Program Coordinator Name*

Home Institution Program Coordinator Email*

Home Institution Program Coordinator Phone*

Phone

Local (Austin) Supervising Physician*

Authorization Form and PLA Upload:*

Please attach the authorization form and the Program Letter of Agreement (PLA) with the receiving Ascension / Dell Med Program Director's or Sponsoring Physician's Signatures. Both documents are required.

Drag and drop files here or

Next Steps

Upon submission of this form Ascension will begin preliminary processing of your application materials and the process will continue as follows.

Preliminary Approval
Attestation & Supervision Grid Request from your coordinator.
Agreement / Amendment Verification and $250 Processing Fee.
You will receive an automatic request with further instructions regarding payment through the Ascension payment portal.
Fee is waived for Military. Houston Methodist, and UTMB Craniofacial Residents.
Once these items are submitted an reviewed you will then receive a New Innovations Login and Checklist. This checklist will require you to upload the following documents:

Rotation Information Form
Letter of Good Standing
Rotator Professional Liability Certificate
Rotator Proof of Health Insurance (If military, a letter of eligibility stating the individual has coverage will suffice)
Rotator Physician in Training/License
Terms of Use Agreement
Rotator Badge Photo
DEA Registration
Compliance Modules
Immunization Records
Respirator Fit Test Record
TB Test Records
Covid-19 Vaccination (Or Exemption)
Influenza Vaccination (Or Exemption)
Hepatitis B Vaccination (Or Exemption)

5. Once your checklist is complete Ascension will submit your provisioning and badge requests. You will be notified when your badges have been created and are ready for pick up.

6.You are cleared to start your rotation.

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