Your contract with the program to which you have recently been appointed will be sent to you at the address provided on your application. Once you receive the Agreement, please review carefully and sign the document. There are two (2) pages which require signatures. Be sure to sign in both places. Return this document no later than April 24, 2009 to:
House Staff Office
Medical Center Blvd.
Winston-Salem, N.C. 27157
You must obtain a Residency Training License prior to beginning your training program. The North Carolina Board of Medical Examiners has made the application available on-line. Please go to:
http://www.ncmedboard.org/licensing/license_application/category/resident_training_license/.
Complete the parts on-line that you can. Print the documents that need to be printed and mailed. The Board has provided a section "Residency Training License Status", where you may go in after the application has been completed and submitted and check the status of your own application.
Your on-line application will be electronically sent to the House Staff Office at this institution. Your application will remain with the House Staff Office until all paper credentials and documents arrive from the sources in which you have requested information. Once all required documentation is received, the House Staff Office will electronically submit the on-line application to the Board and mail the paper credentials and documents for process and review.
If you have difficulty downloading any of the forms within the Residency Training License Application, the forms are being provided here for your convenience.
The House Staff Office will coordinate the application process and act as liaison between you, the applicant, and the North Carolina Medical Board. Unless otherwise indicated during the application process, all paper credentials and documents are to be sent directly to the House Staff Office. Please do not contact the North Carolina Medical Board. If you have any questions or concerns regarding the application process, please direct them to the House Staff Office.
ALL Residency Training License Applications must be submitted to the House Staff Office. These applications should be complete. If your school is one that does not complete the Medical School Certification Form until after graduation, please send your application in without that form. It can be reviewed and held for issuing pending that one form. Please work to have all the other forms and documentation necessary by that time.
Computer generated pictures submitted with the your Medical School Certification Forum are not acceptable. Pictures are required to have a glossy finish and have the school seal imprinted on it.
The license is absolutely necessary in order for you to begin training. Put this first on your list of things to do. Delays in licenses have caused many residents delays in beginning their training. The importance of this application cannot be stressed enough. Do it timely, completely and provide all necessary documentation.
Note: If you have not yet graduated from medical school, your school must complete “Medical School Certification Form A”. If you have graduated already Form B must be completed. If you turn your form into your school and they are not going to process until after graduation, be sure you give them Form B. The Board will not accept the wrong form. Completion of the wrong form has slowed down the licensing process for many entering a training program.
Special Alert Regarding DWI History and Physician Health Program
Please review the 2008 N. C. Medical Board action listed below as it relates to DWI and NC PHP evaluations and referrals. NC PHP, the N. C. Medical Board and N. C. Medical Society function under a Memorandum of Understanding to provide this service. Additional information is located on the following websites http://www.ncphp.org and http://www.ncmedboard.org.
The general requirements for a N. C. resident training license may require that some applicants will need to meet additional requirements and/or meet with a representative of the Board or a subcommittee of the Board as part of the application process. It further notes that this will not be determined until Board staff has reviewed the application. NC PHP and the N.C. Baptist Hospital House Staff Office will notify the applicant if additional information is required.
License applicants will be referred for NC PHP assessment under the following circumstances:
1. Any DWI arrest within the past 5 years.
2. Two or more previous DWI arrest over any period of time.
3. Any DWI arrest where the blood alcohol content (BAC), if available, was greater than 0.14.
4. In some cases, an out-of-state assessment by another state’s PHP, which is known and trusted by the Board, will be accepted in lieu of a NC PHP evaluation.
If the license application is otherwise clean, and NC PHP evaluation, performed in compliance with the criteria above, identified no alcohol or substance abuse problems, no applicant interview will be required with regard to the question of a previous DWI arrest.
BOARD ACTION: Establish the following policy with regard to applicants with DWI History and NC PHP evaluations.
Applicants for license will be referred for NC PHP assessment under any of the following circumstances:
1. Any arrest within the past 5 years for the operation of any vehicle under the influence of any impairing substance.
2. Two or more previous DWI arrest, or the equivalent, over any period of time
3. In some cases and out-of-state assessment by another state’s PHP, which is know and trusted by the Board, will e accepted in lieu of a NC PHP evaluation.
If the license application is otherwise clean, and NC PHP evaluation, performed in compliance with the criteria above, identified no alcohol or substance abuse problems, no applicant interview will be required with regard to the question of a previous DWI arrest.
Location information
NCPHP, 220 Horizon Drive, Suite 218, Raleigh, N. C. 27615, 919 870-4480 or
1 800 783-6792, Fax 919 870-4484.
If you are entering a second year of training or above, you may elect to apply for the Residency Training License or a Full N.C. License. The training license is all that is required. The application for full medical license can also be obtained at the N.C. Medical Board’s website.
If you elect to obtain a full license, all questions and concerns regarding that application must be addressed directly to the Board, not our office. However, please let us know if you are planning to apply for a full license.
The National Provider Identifier (NPI)
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPPA) administrative simple standard. The NPI is a unique identification number for covered health care providers. Covered health care providers, all health plans and health care clearinghouses use NPIs in administrative and financial transactionis adopted under HIPPA.
The NPI is a 10-position, intelligence free, numeric identifier (10 digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medicl specialty.
All house staff is required to have a documented NPI before commencing work. Secure numbers at http://nppes.cms.hhs.gov/NPPES/Welcome.do. If you do not have a N.C. Medical License, you cannot use the taxonomy code for their "Specialty". The "Student" taxonomy code ( 390200000X) is the only one that allows you to enter a Residency Training License (RTL).
When entering a residency training program and obtaining a residency training license, the institution will issue you a DEA number to use within the parameters of your training program. If you obtain a Full North Carolina Licensure and plan to use that license to “Moonlight”, you must apply for and obtain your own DEA number. You can obtain an application for a DEA number on their website www.deadiversion.usdoj.gov/online_forms.htm.
The North Carolina Medical Board, as part of their licensure process, requires a complete criminal background check on all applicants. The release form for your signature is included with the application that you will print from the “Residency Training License” section of the webpage.
You will need to obtain 2 sets of fingerprints. Cards for the fingerprints will be included in the package being mailed to you containing your contract. The fingerprint cards need to be returned with the license application. Important: These fingerprints must be completed by a professional, i.e. Security Office at your institution, local Police Department or Sheriff Department. It is imperative that you do not attempt to do your own prints. Only ink imprints are permitted. Electronic and digital imprints are prohibited.
In addition to the background check required by the Medical Board, North Carolina Baptist Hospital obtains their own background check on all new employees. Please complete the online Criminal Background Check form. Please note: If you lived in any of the states listed on the form additional information and/or additional finger prints may be required.
Once you have matched or have been accepted into a residency program, please complete the New House Staff Information form. Once completed click on the “submit” button and the information will automatically be transferred to the House Staff Office.
Send copies of your ACLS/BLS/PALS / NRP certifications to the House Staff Office. You can send these along with you Agreement (Contract). If you are not certified at this time, you must obtain certification prior to beginning your program. You should get this certification before arriving at this institution. If it is impossible for you to get the training, there will be ACLS/BLS/PALS/NRP Training during New House Officer Orientation. Detailed information is found under Schedule/Agenda in the left navigation box.
All incoming house staff are required to have an Initial Health and Drug Screening provided by this institution’s Employee Health Services. You cannot begin your training program until this requirement is met. Please see the Employee Health Services page for further information.
International Medical School Graduates
Foreign Medical Students accepted into Wake Forest University Baptist Medical Center's programs must adhere to the following protocol:
- Secure a valid ECFMG certificate
- Secure a J-1 visa for those who require a visa to have work authorization.
If you are already on a J-1 visa, you need to submit the paperwork to ECFMG (Education Commission for Foreign Medical Graduates) for a Continuation of Sponsorship and have your training institution transferred to this institution.
If you have never applied to ECFMG for sponsorship before, complete the paperwork for Initial Sponsorship with ECFMG. Both of these documents can be obtained at the ECFMG website. Please be sure and begin this process as soon as possible, as it normally takes 8 to 12 weeks and can take longer. If this documentation is not completed prior to July 1, you can not begin your training program.
Electronic Record Training
Please watch these online education videos prior to orientation. Hands-on classes will occur during orientation. These videos are a prerequisite to the class. Access to our electronic records cannot be provided until this on line training has been completed.
Mandatory Corporate Compliance
Corporate Compliance Training is required training for all hospital employees. Click on 2009 New House Officer Orientation Compliance and HIPAATraining and review the entire module.
Hospital Confidentiality Agreement
Read, sign and submit the Hospital Confidentiality Agreement. The way you sign is by entering in your name, department (Internal Medicine, Pathology, Surgery, etc.) and department number. The department number for all house staff is 795.
Values in Action
Employees are expected to comply with all applicable laws, regulations and the policies of The North Carolina Baptist Hospitals, Incorporated and Subsidiary Organizations and to act with integrity in all situations. Please review the 2009 Code of Conduct as a practical guide to handling important issues for employees. Although it cannot cover every situation, it should be used as a resource to provide general guidance.
Mandatory Bloodborne Pathogen Education/Infection Control Training
Infection Control Training is required training for all hospital employees. Click on NCBH Bloodborne Pathogen Education/Infection Control Annual Training and review the entire module
Medical Records
Incoming house staff must review the material in the Medical Records, then print, sign and return page 4 prior to entering their training program.
Employment Eligibility Verification (Form I-9)
All U.S. employers are responsible for completion and retention of Form 1-9 for each individual they hire for employment in the United States. This includes citizens and noncitizens. On the form, the employer must verify the employment eligibility and identity documents presented by the employee and record the document information on the Form I-9. Acceptable documents are listed on the back of the form, and detailed below under "Special Instructions."
Please access the Employment Eligibility Verification Form at
http://www.uscis.gov/files/form/I-9_IFR_02-02-09.pdf
then print and complete the form. Please bring the completed form and required identification documentation to Human Resources when you come to have your ID badge made. This can be accomplished prior to Orientation.
Payroll Direct Deposit
All employees are required to have their paycheck directly deposited into a bank account. Please print and complete the Payroll Direct Deposit Form. Be sure to attach the appropriate banking information (a blank deposit slip or voided check) so there will be no delay in your receiving your pay. Please mail the completed form to the office with your license application or other materials you are required to send.
Federal and N.C. State Withholding Tax
Prior to beginning your training program you must provide the hospital with federal and N.C. state tax withholding information. Please download, print and complete the forms provided below. Please mail the completed forms into the office with your license application or other materials you may send. Remember you must have these documents completed and turned in prior to beginning your training program.
Orientation Schedule/Agenda
See the Orientation page.
Review the list below and make sure you have completed or taken the appropriate steps to complete all the requirements listed. If not, please complete prior to orientation.
In order to complete each form, be sure to locate and select the Submit/Finish button. The department number is 795. Print Confirm Sheet and send with your package.
Upon Completion of the checklist please submit validation to the House Staff Office, that you have completed all the requirements.
We look forward to your arrival. Please contact the House Staff Office with any questions or concerns.