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US CLINICAL EDUCATION FOR TOMORROW’S PHYSICIANS
Application for Clerkship or Externship
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Applicants are requested to provide the following information voluntarily. This information will not be utilized in a discriminatory manner.
Please provide the following information:
Medical School Information
Please provide names of those who have referred you to our programs (if applicable):
For Non-U.S. Citizens Only
Background Check: A recent national background check is required from ALL applicants and must be submitted with this application. You must also fully disclose all incidents IF ANY to avoid any risk of disciplinary action or revocation of your offer of admission.
Clinical and Health Documents The following documents are required to process your application with the exception of the NYSED Short Term Letter of Eligibility which is required for Clerkships in New York State only (See further instructions below). Clerkships will not be approved until all documents are received and processed.
Please check all items that you will be uploading today.
New York State - Letter of Eligibility Students seeking clerkships in New York State may complete a maximum of 12 weeks of clerkships as per the New York State Education Department (NYSED) rules and regulations. A Letter of Eligibility must be obtained from NYSED to begin clerkships at hospitals in New York State. This Letter of Eligibility must be submitted to MedPathway upon receiving it from NYSED to commence clerkships. *** You must wait for the approval letter from us. This approval letter will not be issued until all your documents have been submitted and reviewed by one of our team members.
Physical: Complete Physical within 1 year if clerkship END date
PPD & Chest X-Ray: Negative PPD/Mantoux screen or FDA approved blood assay (QuantiFeron-Gold) within 1 year of clerkship END date for detection of latent tuberculosis infection, OR documentation of a negative CXR dated anytime after the date of a positive PPD test. A repeat chest X-ray is not required. Note that documentation of a CXR alone without documentation of a prior history of a positive PPD is NOT valid.
Measles Titer: IgG for Measles (Rubeola) if born on or after January 1, 1957, OR documentation of having had the measles disease.
Mumps/Rubella/Varicella Titers: IgG titers for Mumps, Rubella, and Varicella, OR proof of MMR/VZV booster given within 30 days of clerkship/externship start date WITH a MMR/VZV IgG titer follow-up after 30-60 days of the booster being given.
Hepatitis B Titer: IgG surface antibodies for Hepatitis B, OR proof of HepB vaccine series in progress, OR (-) HepB titer WITH (1) proof of completed HepB vaccine series AND (2) proof of HepB booster AND (3) proof of HepB IgG titer follow-up 30-60 days after the booster is given.
Flu Vaccine: Proof of having received the Influenza Vaccine for the CURRENT FLU season (September of current year through March of next year) and either the intramuscular or intranasal formulation. If receipt of the vaccine is contraindicated due to medical condition or prior documented allergic reactions (e.g. anaphylaxis), a physician's note is required to document such exemptions with and explanation of allergic symptoms. Please note that a skin rash is not considered a contraindication to the influenza vaccine.
Drug Screen: 10-Panel Urine Toxicology Screen is NOT required for enrollment in clinical clerkships/externships; however one may be requested upon individual assessment of candidate by hospital/program administration, Undergraduate Medical Education Office, Human Resources or Employee Health office at any given time during the tenure in the program. If requested, a screen will be provided by the hospital. Refusal of such request will result in dismissal from the program.
I understand that this application is for admission only for the term indicated. I agree that I am bound by the Program's regulations concerning application deadlines and admission requirements. I agree to the release of any transcripts and test scores such as USMLE to MedPathway and its affiliates.
I certify that the information provided above and included as attachments is complete and accurate. I understand that making false, fraudulent and/or inconsistent statements within this application will result in any but not limited to disciplinary action, denial of admission, invalidation of credit earned and forfeit of any and all fees paid to MedPathway and its affiliates.
If admitted, I agree to abide by the policies of the rules and regulations of the Program and its hospitals. Should any information change prior to my entry into the Program, I will notify MedPathway immediately.
I understand that credit provided or LOR required for any course is strictly at the discretion of the teaching faculty based on candidates performance during the specific course.
I understand that all documents must be received for processing no later than 4 weeks before the start date for processing.
I understand that all fees must be paid in full 4 weeks prior to the start date to reserve my spot with MedPathway. Under any circumstance, there will be no refunds of any fees paid within this period or beyond. Refer to our website for more information.
I also understand that the application fee I will pay with this application is non-refundable.
Upon submission of this application form and the one-time application fee, your documents will be processed by our credentialing department. Once your file has been processed and if approved, one of the MedPathway specialists will be in touch with you by email with further information regarding your start date and processing your payment for the clerkship/externship. Your seat will only be guaranteed once your payment for the clerkship/externship has been processed.
