Forms

Contacts

Robbin Bankston

Program/Office Manager

RBankston@stanfordhealthcare.org

650-736-7487 (office)

Daily operations / supervision of the GME office
Allowances (Bonuses, On Call Meals, etc.)
Benefits
Payroll
Leave of Absences
Orientation

Marcy Kulakow, BA

Registrar

MKulakow@stanfordhealthcare.org

650-723-5948 (office)

CA Medical Licensure Process
EPIC for House Staff
HealthStream
Incoming House Staff
- HealthStream Compliance
- Occupational Health Compliance
IT for SHC & SCH for House Staff
MSOW Database for House Staff
Visiting Residents
Website Management
Notary

Mitra Haddad, BA

Administrative Coordinator

MHaddad@stanfordhealthcare.org

650-723-5948 (office)

Away Electives Rotations
Continuing House Staff
- HealthStream Compliance
- Occupational Health Compliance
Outgoing/Graduating House Staff
Loan Deferments/Forbearances
Postdoctoral Appointments
Reimbursements
Notary
Jury duty Letter
Certificates

Last Revised 1/23/2018

Forms
Form	Deadline	Contact Person	Note
Away Rotation Application	60 days prior to the start of a new away rotation	Mitra Haddad	House Staff must reach out to Program Director and Program Coordinator regarding away rotation logistics, such as funding and application submission. Then Program Coordinator works closely with the house staff to submit the away rotation request to GME. See Policies & Procedures: Away Elections/Rotations.
Checkout Form for House Staff	last day of training	Mitra Haddad	Must be completed and returned to the GME office to receive Final Paycheck and certificate. Final Paycheck is NOT a direct deposit. See Policies & Procedures: Completion of Training.
Leave of Absence (LOA) Form	30-45 days prior to your first day of leave	Robbin Bankston	Types of LOAs: Bereavement, Family Leave, Jury Duty, Medical Leave (Non Pregnancy, Pregnancy), Paternity, Personal Leave. Prior to working with Matrix, please submit completed GME LOA Form with your Program Director’s signature to Ann Dohn, GME Director, DIO for approval. See Policies & Procedures: Leave of Absence.
Life Support Training Center (LSTC) Registration Form	as needed	Fax to the GME Office 650-723-3045 or e-mail to gme@med.stanford.edu	The GME Office will NOT reimburse you if you pay out of pocket. You must submit the completed LSTC-GME Payment Authorization form for Approval/Sponsorship for payment 3 weeks prior to enrolling in the class. Additionally, the GME Office does not fund or reimburse registration for lapsed recertification’s OR for graduating house staff. See Policies & Procedures: Mandatory Procedures.
Live Scan Service Request	submit form with CA MD License processing	-	This form is a security clearance for CA Medical License processing. To learn more, please visit the Medical Board of California under Questions Regarding Fingerprints.
Reimbursement Form	Varies, please read the form carefully	Mitra Haddad	Please read the form and reimbursement page carefully for various deadlines. Reimbursements are made by payroll and directly deposited to house staff’s account. House staff can confirm receipt of a payment made by payroll by checking their paystub on Lawson eConnect. See Policies & Proecdures: Reimbursements.
Sharps Training Checklist	September	Occupational Health
Welch Road Apartment Application Form	Before May 1st	gme@med.stanford.edu	Lottery packet/guidelines are sent to new/incoming house staff along with their contracts in the Spring. To learn more, read more about Welch Road Apartments here.