University of South Florida
University of South Florida
College of Medicine
AUTHORIZATION FOR CLINICAL ACTIVITY BY FACULTY
IN UNAFFILIATED INSTITUTIONS
Faculty Member: Dept.:
Date(s) of Activity: URGENT-DEPT. FAX
Location of Activity:
Unique Purpose of Activity:
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Authorization by Department Chair:
I authorize the clinical activity indicated above as being within the scope of duties of this faculty member and concur with the unique nature of this faculty experience.
Date: Signed: , M.D.
Chairman, Department of
Administrative Concurrence:
The unique clinical activity described above has been granted administrative concurrence and is recommended by the Office of the Dean for Self-Insurance Program coverage.
Date: Signed:
Valerie M. Parisi, MD, MPH, MBA
Senior Vice President for Faculty and Academic Affairs USF Health- MDC 49
Self-Insurance Program Coverage:
USF Health Sciences Center Self-Insurance Program coverage is extended to include the clinical activity described above on the dates indicated.
Date: Signed:
Courtney Rice, Esq.
Director, USFHSC Self-Insurance Program-MDC 43
THIS ORIGINAL DOCUMENT WITH ALL SIGNATURES IS TO BE FILED WITH
OFFICE OF FACULTY AFFAIRS-MDC 53
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