School of Medicine Affiliate Request

SOM Affiliate Request

Request School of Medicine Affiliation for Hospital Associates and Research Collaborators

Name(Required)

First Middle Last

Birth Date:(Required)

Date of Birth

Gender(Required)

Primary Phone #(Required)

PID (If Known)

Benefits Program Participation(Required)

Do you get your benefits through NC Health Benefits or through State Benefits?

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Business Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Affiliate Department (Surgery, Internal Medicine, Pediatrics, etc)(Required)

University Sponsor / PI / Residency Director(Required)

Business Reason for Affiliate Request(Required)

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