BERKSHIREMEDICALCENTER (BMC)

RESIDENCY PROGRAM APPOINTMENT AGREEMENT

NAME: ______PROGRAM: ______

DENTALSCHOOL: ______

DATE OF GRADUATION: ______PGY LEVEL: ______

EFFECTIVE DATES: FROM ______TO ______

BerkshireMedicalCenter:

  1. Appoints the above-named dentist to a residency position.
  2. Agrees to provide an educational program that meets the Accreditation Standards established by the Commission on Dental Accreditation for the American Dental Association (ADA).
  3. Agrees to provide a stipend; vacation, sick and other leave; professional liability; health insurance and other benefits; and due process procedures as specified in the BMC ResidencyPrograms Personnel Policies and in the BMC Personnel Contract.

The Resident:

  1. Has received a copy of the BMC Residency Programs Personnel Policies, and agrees to abide by the policies, procedures and regulations therein, and to the bylaws and policies of BMC and of any hospitals, clinics and offices to which the Resident is assigned.
  2. Agrees to fulfill the educational and clinical responsibilities of the General Practice Residency in Dentistry training program as stated in the ADA and other approved standards; and in accordance with the policies, procedures, and goals of the Residency Program.
  3. Agrees to the release of information, by the professional liability program pertaining to the Resident’s professional practice, and agrees to report to BMC or its agent(s) incidents involving potential liability during the performance of professional services as part of the care setting, and agrees to provide reasonable cooperation in the investigation and defense of any such incident by BMC.
  4. Shall have a valid Massachusetts Full or Limited License to practice dentistry throughout the appointment; and, as appropriate, a proper visa. Failure to maintain such license shall be grounds for termination.
  5. Agrees and authorizes Berkshire Health Systems to investigate all pertinent information upon

hire in order to determine the requisite qualifications for employment. Anyfalsification,

misrepresentation or omission of facts called for in the hiring process may result in denial of

employment or immediate dismissal. It is also agreed that internship and residency offers are

conditional on submission of satisfactory proof of legal eligibility to work in the United

States, and on satisfactory results of a background check, references, drug testing and

physical examination given by medical personnel at Berkshire Health Systems at the time of hire.

The Resident hereby accepts this appointment:

______

ResidentDate

______

Department Chair (or Designee) Date

______

Associate Dean/Designated Institutional Official Daterev 2-13-07

BERKSHIREMEDICALCENTER (BMC)

RESIDENCY PROGRAM APPOINTMENT AGREEMENT

NAME: ______PROGRAM: ______

MEDICALSCHOOL: ______

DATE OF GRADUATION: ______PGY LEVEL: ______

EFFECTIVE DATES: FROM ______TO ______

BerkshireMedicalCenter:

  1. Appoints the above-named physician to a residency position.
  2. Agrees to provide an educational program that meets the General and Special Requirements of the “Essentials of Accredited Residencies” as established by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA).
  3. Agrees to provide a stipend; vacation, sick and other leave; professional liability; health insurance and other benefits; and due process procedures as specified in the BMC ResidencyPrograms Personnel Policies and in the BMC Personnel Contract.

The Resident:

  1. Has received a copy of the BMC Residency Programs Personnel Policies, and agrees to abide by the policies, procedures and regulations therein, and to the bylaws and policies of BMC and of any hospitals, clinics and offices to which the Resident is assigned.
  2. Agrees to fulfill the educational and clinical responsibilities of the graduate medical education training program as stated in the ACGME Special Requirements and other approved standards; and in accordance with the policies, procedures, and goals of the Residency Program.
  3. Agrees to the release of information, by the professional liability program pertaining to the Resident’s professional practice, and agrees to report to BMC or its agent(s) incidents involving potential liability during the performance of professional services as part of the care setting, and agrees to provide reasonable cooperation in the investigation and defense of any such incident by BMC.
  4. Shall have a valid Massachusetts Full or Limited License to practice medicine throughout the appointment; and, as appropriate, a proper visa. Failure to maintain such license shall be grounds for termination.
  5. Agrees and authorizes Berkshire Health Systems to investigate all pertinent information upon

hire in order to determine the requisite qualifications for employment. Any falsification,

misrepresentation or omission of facts called for in the hiring process may result in denial of

employment or immediate dismissal. It is also agreed that internship and residency offers are

conditional on submission of satisfactory proof of legal eligibility to work in the United States,

and on satisfactory results of a background check, references, drug testing and physical

examination given by medical personnel at Berkshire Health Systems at the time of hire.

The Resident hereby accepts this appointment:

______

Resident Date

______

Department Chair (or Designee) Date

______

Associate Dean/Designated Institutional Official Daterev 2-13-07