Required Documentation Checklist

GME Required Documentation and Deadlines
Pay close attention to all deadlines for submission of forms!
All documents can be found on the
GME Residents and Fellows/GME Office/Welcome Paperwork page on the DHMC Website
Please work your way through this list in order and follow the directions CAREFULLY!
There are different due dates for each stage in the hiring process.
Please note: this is a 3 page document
DEADLINE: MONDAY, APRIL 20TH
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The mandatory Drug Screening must be completed by this date. You will receive an email
from LabCorp on April 6th with instructions.
DEADLINE: MONDAY, APRIL 20TH
Occupational Medicine Pre-Placement Health Questionnaire
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After completion, mail the questionnaire along with a current copy of your
immunization records (NOTE: ppd results must be after January 1, 2015) to:
Occupational Medicine
Dartmouth-Hitchcock Medical Center
One Medical Center Drive
Lebanon, NH 03756
Attn: Paul Boyle
DO NOT send this information to the GME office or to your program. This is confidential
health information and should be sent directly to Occ Med.
DEADLINE: FRIDAY, APRIL 24TH
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I need a good quality headshot for the GME Housestaff Poster.
Please email me either a color or b/w picture (.jpg preferred)
Send to:
Regina.M.Beaty@Hitchcock.org
DEADLINE: FRIDAY, MAY 1ST
After completion, please print and mail the first two forms to:
Graduate Medical Education
Dartmouth-Hitchcock Medical Center
One Medical Center Drive
Lebanon, NH 03756
Attn: Regina Beaty
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Please do not fax or email these forms, I need the original documents – thanks!
Applicant Disclaimer and Consent form
• The checkboxes can be filled out electronically, printed for signature and mailed.
Lab Coat Order form
• You can fill out this form electronically. You will be given the opportunity to exchange
the size at orientation if it doesn’t fit correctly. This form is mailed to the GME office.
NPI House Staff memo (any questions contact: Mary.Lou.Previte@hitchcock.org )
Part 1: Once you register with CMS (through the CMS Registration Video), you will have
created an account. Use this User ID and Password for Part 2 of the NPI Process.
Part 2: You will need to apply for an NPI number for billing purposes. Part One consists of an
online video and Part Two is the NPI House Staff Memo. There is no cost and the form is not
mailed back.
DEADLINE: FRIDAY, MAY 1ST
Background screening process for Dartmouth Hitchcock
In complying with New Hampshire regulatory requirements and internal policy, DartmouthHitchcock requires all residents and fellows to undergo an extensive background check through
PT Research, a Consumer Reporting Agency. This background check searches for criminal
records, sex offender status, and exclusions from federal health programs. If you have a
criminal record it will not automatically bar you from participating in Dartmouth-Hitchcock’s
residency and fellowship programs, and we encourage you to disclose this information before it
is discovered on a background check.
In order to complete the background check, ALL of the following steps must be taken:
1. Complete the 3-page background check authorization form by clicking on the link found
on the Welcome Paperwork website.
Please note that while the form references the Consumer Reports and the Fair Credit
Reporting Act, Dartmouth-Hitchcock will not request or obtain your personal credit report.
2. Print the NH Department of Safety CRIMINAL RECORD RELEASE AUTHORIZATION
FORM and complete Section I in its entirety.
3. Complete Section II in the presence of a Notary Public and leave the last line blank
(Signature of person/firm to receive record).
4. Mail the original notarized form to (do not mail to the GME office):
PT Research, Inc.
P.O. Box 4540
Manchester, NH 03108
Please do not include payment as noted on the bottom of the form. Payment will be
handled by PT Research.
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The following forms need to be brought to Orientation
(do not mail or email any of these forms):
Passport or Permanent Resident Card (if you have neither then you absolutely must bring a
Driver’s License/State ID/Military ID and a Social Security card or Birth Certificate)
• If you come to orientation without identification you will not be allowed to start your
residency or fellowship on time.
I-9 Employment Verification
• Complete Section 1 ONLY! Bring this form with you to orientation.
• Refer to the I-9 Document Samples and List form for appropriate types of identification
needed. MAKE SURE TO BRING YOUR IDENTIFICATION TO ORIENTATION!
• Do not mail this form to the GME office, bring this to orientation
Windows password worksheet (hint: enter the info into your smartphone so it is available
during orientation)
And…for Non-VISA Housestaff only:
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W-4 form – Do not mail this form to the GME office, bring this to orientation
For VISA Housestaff only:
Foreign National Form
• This form will need to be printed and completed by hand
• A copy of both sides of your I-94 “Arrival and Departure Record” must be attached
before returning.
A copy of your US Visa from your passport must be attached before returning.
A copy of your I-20 or IAP66 must be attached before returning.
Do not mail this information to the GME office, bring this form and all supporting
documentation to orientation
W-4 instructions and form for Non-Resident Aliens
• This is to be used as an example ONLY! Please use this info to help you fill out the W-4.
• Do not mail this form to the GME office, bring the completed form to orientation.
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For your reference only, no signatures are needed, these forms are not mailed back
" DH Privacy and Confidentiality of Patient Information Policy
" DH Privacy Practices
" Summary of Your Rights
" FCRA Notice for Background checks
o This is information related to the mandatory background screening.
I have uploaded a brochure from Housing Solutions in Hanover, New Hampshire to the Residents and
Fellows website. This brochure is located at the bottom of the page under all these documents. If you are
looking for a house or apartment to rent or buy, Sarah Barnes would be happy to help!
There is also a brochure from Timberwood Commons, an apartment complex located ¼ mile from
DHMC. Timberwood does list their units with Housing Solutions as well.