Required Forms to Complete
IUSM Required Documents You Should Complete and Submit
I. Documentation to submit to your residency/fellowship coordinator 30 days prior to the start of your training:
All USMLE transcripts
Signed Letter of Appointment
Signed Statement of Principles (Honor Code)
Verification of prior graduate medical education (for PGY 2s and above)
Medical/dental school diploma
Valid Indiana medical/dental license
Valid National Provider Identifier (NPI) number (click here for instructions)
II. Forms/Documents to complete and submit to your residency/fellowship coordinator prior to your start date: (click on link)
I-9 Electronic Form (You will be sent a link via email from HireRite. Original documents must be presented in person to your program coordinator)
Bank Direct Deposit Electronic Form (Must have already created IUSM username and passphrase to access, then click on Services tab, next click on Employee Center in the left navigation menu, under Payroll Information click on Direct Deposit link to enroll)
W-4 Federal Tax Form (A local permanent address is necessary to complete this form.)
WH-4 State Tax Form (A local permanent address is necessary to complete this form.)
Cigna Beneficiary Form (for life insurance)
Anthem Medical & Cigna Dental Electronic Enrollment Forms
House Staff Information Form
Immunization Verification Form
Patent Agreement Form
Motor Vehicle Records Check Electronic Form (Must have SS# to enroll online, those with out a SS# must complete the paper version) Click here for paper version.
Wishard Hospital Pharmacy Signature Form (A valid Indiana medical/dental license number is needed.)
IU Health Hospitals Pharmacy Signature Form (A valid Indiana medical/dental license number is needed.)
VAMC Application for Health Professions Trainees
VAMC Trainee Registration Information for Vista
VAMC Declaration for Federal Employment
VAMC Appointment Affidavits
VAMC Rules of Behavior
ATTENTION: Residents and fellows in the following programs only - DO NOT print and complete the VAMC forms above.
Emergency Medicine | Emergency Medicine/Pediatrics | Family Practice-Sports Medicine | OB-Female Pelvic | Ortho/Hand | Pediatric Dentistry | Pediatric Surgery | Pediatrics | Urology-Pediatric
III. Form to complete and take to fit testing site (scheduled by program coordinator):
IV. Forms to be submitted by international medical graduates:(Should be submitted to program coordinator before start of training)
Initial Standard J-1 Visa Application-submitted 6 to 8 weeks before start of training
http://www.ecfmg.org/evsp/evspicln.pdf
or
Initial Non-Standard J-1 Application-submitted 8 to 10 weeks before start of training
http://www.ecfmg.org/evsp/evspinsc.pdf
ECFMG certificate
Validation of Initial Arrival of J-1 Physician for reporting to Sevis Form must be signed by TPL as well as have supporting documentation such as the I-94, adjudicated DS-2019 and copy of J-1 passport page.
International Tax Questionnaire
W-4 Federal Tax Form for Non-Resident Aliens
