School of Medicine Affiliate Request

SOM Affiliate Request

Request School of Medicine Affiliation for Hospital Associates and Research Collaborators

Business Justification and Access Needs

Please outline the business justification for needing a School of Medicine affiliation, including each of the websites, systems, or shared drives you need access to:(Required)

Department and Sponsor Details

Please list the School of Medicine Department or Center you are working with:(Required)

Please list the first and last name of your School of Medicine sponsor, PI, or residency director associated with your affiliate request:(Required)

Details of Person Needing Affiliate Status

Please provide your full name:(Required)

First Middle Last

Birth Date:(Required)

Date of Birth

Gender(Required)

Primary Phone #(Required)

PID (If Known)

Please select your primary employer:

黑料网 Health

黑料网 Rex

NC Health

Other

Please select your Benefits Plan, if applicable:(Required)

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

Please enter your email contact:(Required)

Please enter your home address:(Required)

Street Address Address Line 2 City State ZIP Code

Please enter your business address:(Required)

Street Address Address Line 2 City State ZIP Code

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