Frequently Requested Forms
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TRAINEE APPOINTMENT AND COMPLETION FORMS
- Appointment Letter
- Appointment Letter Request Form (Residents & Fellows) -Updated 1/12/2012
- Certificate Engrossing Request Form- Updated 9/1/2011 (see requirements and updated fees)
- IU Health Hospital Pharmacy Signature Form
- Exit Form for Terminating House Staff
- Health Services Authorization to Medical Release Information Form
- House Staff Information Form
- Health Services Immunization Form (also known as Resident Immunization Verification Form)
- Jagtag/School of Medicine ID Card Expense Authorization Form
- Motor Vehicle Records Check Form
- Patent Agreement Form
- Temporary and Visiting House Staff Assignment Form
- TB Respirator Questionnaire *for fit testing and TB masks
- Wishard Hospital Pharmacy Signature Form
Background Check Information and Forms
*Copy of resident/fellow CV requested with formsUpdate - Policies and Procedures for Requesting Background Checks
- Acknowledgement of Receipt of Conditions and Requirements for Appointment Updated 12/9/2011
- Background Check Request Cover Sheet
- Consent to Background Check
- Background Check Self-Disclosure Questionnaire
- Statement of Principles-Honor Code
BENEFIT FORMS
- Cigna Beneficiary Form (life insurance)
- Fee Courtesy Form (with instructions)
- Waiver of GME Insurance Coverage
- All Other GME Benefit Forms
PAYROLL FORMS
- Direct Bank Deposit Form
*Note: The Payroll Department prefers that direct deposit information be changed electronically via OneStart. To log into OneStart, click here. Direct deposit changes can be made in the "Employee Self-Service" menu on the right. - W-4 Tax Form (Federal)
*Note: Current trainees can send all tax form updates directly to the Office of Financial Services, UN 442. - WH-4 Tax Form (State)
- W-4 Federal Tax Form for Non-Resident Aliens
- International Tax Questionnaire (International Medical Grads)
MISCELLANEOUS FORMS
- Authorization for Release of Information
- Leave of Absence Form - Family Medical Leave (FMLA) -Updated 11/1/2011
- Leave of Absence Form - Standard Leave(LOA) -Updated 11/1/2011
- Moonlighting Activity Form
- Paging Equipment Agreement
- Personal Data Change Form
- Personal Profile Form
- Request for IUSM Graduate Student Records
- Program Letter of Agreement Template
VAMC Forms
- Application for Health Professions Trainees
- Trainee Registration Information for Vista form
Please submit completed VAMC form(s) to Alicia Fleener, VAMC Rm. 11E.

Fesler Hall is located south of Riley hospital;
west of the Nursing School.

