STUDENT APPLICATION FOR ELECTIVE STUDY

INSTRUCTIONS

Please print the following application and fill out accordingly. Mail it to the address listed below. Application must be completed noting student data, student request, insurance coverage, immunizations, and academic standing. The student must assume responsibility for the completion of the application.

TO COMPLETE THE APPLICATION

A non-refundable $75.00 application fee made payable to Indiana University.
Fill in name, Social Security number, current mailing address, e-mail address, present medical school, and expected date of graduation.
List by Indiana University School of Medicine course number, the elective(s) and respective title(s) you prefer. Please list a minimum of three (3) alternatives, in case your preferred course is not available. Note the inclusive dates you choose to take the elective(s). Please list alternate dates/months to increase the opportunity of meeting your request. Sign and date the application.
Have the Dean or authorized official complete the remaining section regarding your insurance coverage and academic standing.
Send completed application to:
John Keller
Indiana University School of Medicine
635 Barnhill Drive, MS 159
Indianapolis, IN 46202
(317) 274-2264, E-mail: jodkelle@iupui.edu
Completed applications are due at least eight (8) weeks prior to start of an elective. The cancellation and request for change in an elective already scheduled will be reviewed once all other requests are confirmed. Missing application items may slow the confirmation process. Requesting multiple electives should be done when sending your initial application. Adding electives at a later date will slow the confirmation process or may not be possible due to time constraints.
Guest applications will be processed beginning May 15 of each new academic year. Applications are approved as soon as possible and confirmed on a month to month basis.

TO BE COMPLETED BY STUDENT - STUDENT DATA

Name___________________________

Home School ID# or Last 5 digits of DL# ________________ (for computer security access)

Address____________________________________ City___________ State____ Zip________

Phone #_________________ E-mail:________________

Current Medical School____________________________ Date of Graduation_________

REQUESTS
List, by course number and course title, the elective course you prefer. Also list acceptable alternate courses and month/dates. Elective Catalog 2006/2007

	Course #	Start Date	End Date	Course Title
Preferred
Alternate 1
Alternate 2
Alternate 3

STUDENT'S SIGNATURE________________________________________

INSURANCE COVERAGE AND ACADEMIC STANDING
NOTE: THE INDIANA UNIVERSITY SCHOOL OF MEDICINE DOES NOT PROVIDE PERSONAL HEALTH OR PROFESSIONAL LIABILITY INSURANCE COVERAGE TO STUDENTS FROM OTHER SCHOOLS. THE STUDENT WILL BE REQUIRED TO PROVIDE HIS/HER OWN PERSONAL HEALTH INSURANCE AND PROFESSIONAL LIABILITY WHILE ON A SENIOR ELECTIVE AT THE INDIANA UNIVERSITY SCHOOL OF MEDICINE.

TO BE COMPLETED BY THE DEAN OR AUTHORIZED OFFICIAL OF THE STUDENT'S MEDICAL SCHOOL.

	YES	NO
1) Is the above mentioned student in good academic standing at your institution?
2) Is the student officially enrolled at your institution and in his/her 4th year (senior) of medical school?
3) Will the student have completed your institution's required clinical training in the area (s) relevant to the requested elective prior to beginning study at Indiana University?
4) Will the student's personal health coverage be in effect while studying at Indiana University?
5) Will the student's professional liability insurance be in effect while studying at Indiana University?
6) Is he/she approved to take this course for credit?
7) At the conclusion of the elective, will an evaluation be required?
If yes: ____ Use IU eval ____ Use attached guest eval ____Guest eval to be forwarded later

Name of Dean or Authorized Official: Name and Email Address of Electives Coordinator
(Official confirmation will be sent to this person)

_________________________________ ______________________ Email: _________________

Street Address, City, State, Zip

_______________________________________________________

Phone Number_____________________ Fax Number_________________________

Signature of Dean or Authorized Official:

_______________________________________________________

HIPAA Privacy Training Summary Checklist

HIPAA information below is specific for the Indiana University School of Medicine. While you may have completed a form like this at your home school, signature on this form is necessary to be compliant with the HIPAA requirements for IUSM.

HIPAA Privacy Training Summary Checklist

As a guest student of Indiana University School of Medicine, I understand that at times, I may have access to health care information and other privileged documents. As such, I understand and agree that the following guidelines should be followed when handling such items.

Introduction:

HIPAA is the Health Insurance Portability & Accountability Act of 1996
HIPAA required Congress to enact a comprehensive privacy law; if not done by August of 1999, the Department of Health and Human Services (HHS) was required to address this.
The Department of Health and Human Services published the Privacy regulation December 2000 with an effective date of April 14, 2003.
For a full summary of information regarding the United States Department of Health and Human Services HIPAA Privacy Rule, please go to http://www.hhs.gov/ocr/privacysummary.pdf.

Who Must Comply?

“All Covered Entities” (CE), which includes health plans, health care clearinghouses, and those healthcare providers who conduct financial and administrative transactions electronically. This includes the entity for whom you will be providing service for at Indiana University and its affiliates.

What is Protected Health Information (PHI)?

· Individually identifiable health information

· Transmitted or maintained in any form or medium

This includes patient records in printed or electronic format or oral communication

This would include any information including demographic information that:

® Is collected from an individual

® Is created or received by a covered entity

® Relates to the past, present, or future physical or mental health condition of an individual

® Relates to the provision of health care to an individual

® Relates to the past, present, or future payment for the provision of health care to an individual

® Identifies the individual where there is reasonable basis to believe that the information can be used to identify the individual

What areas do the Privacy Rules affect? (See Incidental uses and disclosures section found at http://www.hhs.gov/ocr/hipaa/guidelines/incidentalud.pdf.)

· Any and all areas that deal with PHI

· It does not matter that you or your department does not see patients

· It includes testing results, research, and billing records that contain health information

· Students, trainees, volunteers and other persons who have access to PHI are affected

· It includes what you store on computers, desks, files, off-site storage, disks, etc.

· It affects what you say, to whom it is said and what information you are providing.

What are the Minimum Necessary Requirements? (See Minimum necessary section found at

http://www.hhs.gov/ocr/hipaa/guidelines/minimumnecessary.pdf)

· HIPAA requires that you take reasonable steps to limit the use, disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose.

· What PHI is reasonably necessary is determined on a case by case basis by the CE.

· This does not apply to disclosures for treatment purposes, but to payment, health care operations and research.

What happens if you violate the Privacy Rule?

· Civil penalties ($100 per violation per person, up to a limit of $25,000 for violating each identical requirement or prohibition) may apply.

· Criminal penalties –

® Knowing release of PHI – up to 1 year jail sentence & $50,000 fine

® Access to PHI under false pretenses – up to 5 year jail sentence & $100,000 fine

® Releasing PHI with intent to sell, transfer or use for commercial advantage – up to 10 year jail sentence & $250,000 fine

What policies are applicable?

I understand that by signing below, I have been provided with access to and have read the above policies involving the protection of privacy that may apply to the services I will be providing.
I further understand, that as a guest of Indiana University School of Medicine, I may directly or indirectly have access to PHI held by other entities. I understand that disclosure of this information that is not required as part of my job functions is prohibited.

I hereby certify that I have read this document and web attachments and am aware of confidentiality requirements expected of me as a guest of Indiana University School of Medicine.

________________________ ________________________ __________
Signature Print Name Date

________________________ From:______________To:________________
Home School Dates attending as guest of IUSOM

MAIL UPON COMPLETION TO:

Guest Student Coordinator
IUSOM - MSA
635 Barnhill Drive - MS 159
Indianapolis, IN 46202
FAX - 317-278-4755

Immunization Form
MSA