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Resident and Fellow Policy Manual

Appendix 1 - Moonlighting Instructions:

Please Complete and Send to the Medical Staff Office the Forms on the Following 7 Pages:

  1. Strong Health Moonlighting (extra work shift) Request Form, p. 1 of 7
  2. Strong Health System Credentials & Privilege Review, p. 2 and 3 of 7
  3. DEA or DEA Statement.  If you are using SMH's or HH's DEA number, submit the DEA Statement with the suffix #, otherwise a copy of your own DEA, p. 4 of 7
  4. SMH SOA p. 5 of 7 and/or HH SOA(Statement of Assurances), p. 6 of 7
  5. Consent to Release of Information, p. 7 of 7

Please Send to the Medical Staff Office the Following Additional Items:

  1. Your CV (curriculum vitae)
  2. Health/PPD form
  3. Your Delineation of Competencies listing
  4. New York State License, a copy of the original license and original registration with expiration date