HOUSE STAFF POLICIES AND PROCEDURES MANUAL

Appendix D – MOONLIGHTING

Request to Moonlight at a facility outside the Grady                 Healthcare system or  EMORY HEALTHCARE

        · I submit this request to be approved to moonlight during the period __________________
            (The period may not be longer than six months);
· I agree to have a signed contract to moonlight at ____________________________(Name of hospital(s) or other facility).  The contract must state that the facility will provide professional liability insurance coverage with respect to the services that I provide during my moonlighting assignment or that I have my own personal professional liability insurance to cover this moonlighting.
· I am fully licensed to practice medicine in the state where the moonlighting will occur;
· I am NOT in training on a J-1 visa;
· I agree NOT to wear anything identifying me as a trainee in the Emory training program (including, but not limited, to Emory photo ID cards, uniforms, lab coats);
· I agree not to exceed any restrictions the training program has regarding the total number of hours I may work per week;
· I acknowledge any activities, including moonlighting, which interfere with residency training or impact on my performance in the training program may be grounds for disciplinary action up to and including my dismissal from the residency program;

By signing below, I attest to the completeness and accuracy of the above information.

                                                                                                                        ___________
Signature of resident requesting permission to moonlight                       Date

_____________________________________________          
Print name of resident/ PGY

Request for moonlighting   is     is not   (circle one) approved

______________________________________                                        ____________                          
Signature of Program Director                                                                      Date                                                      

Request to Moonlight in the EMORY HEALTHCARE system 

·               I submit this request to be approved to moonlight during the period__________________ 
   (The period may not be longer than six months);

·             I agree to have a valid contract to moonlight at______________________( Name of Emory Healthcare facility).  The contract must state that the facility will provide professional liability insurance coverage with respect to the services that I provide during my moonlighting assignment.

·               I am fully licensed to practice medicine in the state where the moonlighting will occur;

·               I am NOT in training on a J-1 visa;

·               I agree not to exceed any restrictions the training program has regarding the total number of hours I may work per week;

·               I acknowledge any activities, including moonlighting, which interfere with residency  training or impact on my performance in the training program may be grounds for discipline up to and including my dismissal from the residency program;

·              I understand I may moonlight only in outpatient settings or in the Emergency Department;

By signing below, I attest to the completeness and accuracy of the above information.                                                                                                                                                                                                              

_____________________________________________                                ____________
Signature of resident requesting permission to moonlight                                   Date

 ___________________________________________                           
Print name of resident/ PGY

Request for moonlighting   is     is not   (circle one) approved

____________________________________________                                   ______________   
Signature of Program Director                                                                        Date

Site Designed and Maintained by School of Medicine Information Technology Services
© 2005 Emory University. Last Update: July-05