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Appendix D: Moonlighting

Request to Moonlight at a facility outside the Emory Healthcare or Grady Health 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 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 or Grady Health 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

Email gme@emory.edu to request a Moonlighting Form.