UPRT Request Form

COMPLETE THIS SECTION FOR NEW OR REPLACEMENT POSITIONS
Position Information
BCAP Number: Required / BCAP Proposal Name:
Name of position: (e.g, cardiology-NP; imaging-body)
Is this a new position?: Yes No Required
If yes, anticipated commencement date: / Is this a Replacement Position: Yes No
Required If yes, name of incumbent:
Incumbent’s termination date:
If this is a new position, has it been reviewed by the Strategic Growth Committee?: Yes No Required
If yes, date of review:
Is this a budgeted position: Yes No / Is there an identified candidate? ?: Yes No
If yes, name of candidate:
Org/AU (or CC): USE BANNER AFFILIATION ACCT (cost center) / Benefitting Facility Name: Identify hospital this physician would primarily admit patients.
B-UMCP
B-UMCT
B-UMCT So / Benefitting Facility Code:
(contact Donna to see if she has a list of codes)
Position ID: Required / Position Title:
Faculty Physician / Physician Specialty:
PS Code: See list on legal website / PS Code Specialty: See list on legal website
Clinical Dept/Division: Required / Faculty Title: Required / Primary Employer: Required
UA (Tenure/Tenure Track/Chair/Vice Chair/Division Cheif)
B--UMG (Non-tenure)
Employment Status: Required
Full Time
Part Time
Per Diem
Total FTE: / Distribution of Effort: Required
Clinical: %
Teaching: %
Research: %
Leadership/Admin (B--UMG): %
Leadership/Admin (COM): %
Leadership/Admin (Banner): %
Other: %
100%
If Other, describe in detail:
Describe how this position aligns with your service line strategy and complete the Productivity/Funding Tool and submit it with the completed UPRT Request Form:
(Be prepared to briefly review this information at the UPRT meeting. Identify in detail how this position will address a specific need: increased patient satisfaction, fulfill a gap in services, identify cost savings, etc. Please also describe the program size and how this request compares to similar positions inside and outside of B—UMG)
Compensation Information (Complete Every Item; Use N/A As Applicable)
Base Salary: / Salary Guaranty: Yes No
WRVU Incentive: N/A (in Tucson) / Recruitment (Signing & Moving) Incentive: Only if applicable (Use $15,385 for Moving)
Signing Bonus: Moving:
Medical Director Compensation: Only if applicable / Extra Shift Compensation: Only if applicable
Description of Call Coverage Obligation: Fill in if applicable / Excess Call Coverage Compensation: Only if applicable
Other Compensation: / Cap on Compensation: Yes No
Package Information (if any)
Is there a package being offered with this position?: Yes No If you anticipate a package because the position being requested is for a chair, division chief, etc. please indicate yes and estimate as best you can what that might include below or indicate package will be presented for approval after candidate identified
If yes, describe in detail, including maximum amount of total package:
Is the position part of an existing package?: Yes No If position is being requested because it was a position designated in a package provided for a chair, division chief, etc., indicate yes and provide details below
If yes, describe in detail, including amount of original package approved and amount of approved package remaining:
Practice/Candidate Information
Practice Name: location where Physician is practicing / Practice Address:
Practice Contact Information: Phone: DIV/PRAC MGR INFO Fax: Email:
Practice Contact and OPS Director: DIV/PRAC MGR / Practice Tax ID: N/A
Required Credentials and/or Specific Requirements for Position: MD, PHD, Certification if necessary
Years Practice in Existence: / Procedures:
Average Outpatient Visits per Week: BASED ON CANDIDATE EXPECTATION / Monthly Average: / No. of Patients Expected to See per Day:
Call Schedule: IF APPLICABLE, WHAT AMOUNT ( 2 months per year, 1 week per month,etc)
Procedures/Types of Cases: R=Required D=Desirable N=Not Available U=Unnecessary: Base on Division expectation
Financial Data: Please Enter Payer Mix by Percentages:USE FPSC FOR DIVISION Medicare: Managed Care: Medicaid: Indemnity: Worker’s Comp: Private Pay: Other:
Service Area: Tucson, Sierra Vista, etc. / Facility and Community Websites: N/A (Until further info)
Number of physicians in the Practice: / Names and Specialties: / Number of Open Positions:
Recruiter Name: Denise Bundgaard or Toni Jones / Recruiter Phone Number:
Completed By: / Date:
COMPLETE THIS SECTION FOR EXISTING EMPLOYEES
Amendment Information
Employee Name: / Original Employment Commencement Date:
LMS or Meditract Number: / Amendment Number:
Is this a budgeted change?: Yes No / Proposed effective date of change:
Org/AU (or CC): / Benefitting Facility Name:
B-UMCP
B-UMCT
B-UMCT So / Benefitting Facility Code:
Position ID: / Position Title: / Physician Specialty:
PS Code: / PS Code Specialty:
Clinical Dept/Division: / Faculty Title: / Primary Employer:
UA (Tenure)
B--UMG (non-tenure)
Current Employment Status:
Full Time
Part Time
Per Diem
Current Total FTE: / Proposed Employment Status:
Full Time
Part Time
Per Diem
Proposed Total FTE:
Describe how the proposed changes aligns with your service line strategy:
(Be prepared to briefly review this information at the UPRT meeting. Identify in detail how this position will address a specific need: increased patient satisfaction, fulfill a gap in services, identify cost savings, etc. Please also describe the program size and how this request compares to similar positions inside and outside of B—UMG)
Compensation/Distribution of Effort Information (Complete Every Item; Use N/A As Applicable)
Current Compensation Arrangement: Required
Base Salary:
Salary Guaranty: Yes No
WRVU Incentive:
Extra Shift Compensation:
Medical Director Compensation:
Description of Call Coverage Obligation:
Excess Call Coverage Compensation:
Outstanding Recruitment Incentive:
Other Compensation:
Cap on Compensation: Yes No / Proposed Compensation Arrangement: Required
Base Salary:
Salary Guaranty: Yes No
WRVU Incentive:
Extra Shift Compensation:
Medical Director Compensation:
Description of Call Coverage Obligation:
Excess Call Coverage Compensation:
Outstanding Recruitment Incentive:
Other Compensation:
Cap on Compensation: Yes No
Original Package Amount (if any): / Remaining Package Amount (if any):
Describe the rationale for the proposed changes in compensation and complete the Request for Change Effort and Funding form and submit it with UPRT Request Form if there is a proposed change in clinical FTE allocation or funding allocation:
Secondary Professional Activities
Does Employee provide clinical or administrative services to any entity other than UA/B—UMG as part of Employee’s employment with UA/B—UMG? Yes No
If yes, describe in detail: Ex: Medical Directorship/Administrative Role for outside organization with compensation/ funding attached.
Completed By: / Date:
COMPLETE THIS SECTION FOR ALL REQUESTS
Hiring Authority Information
B--UMG Physician Leader: Dept. Chair/Div Chief/Med. Dir for clinic site / Lawson Reporting Relationship: / Lawson ID:
B--UMG Exec. Dir./Pr. Admin: Dept. Admin / Requestor/Hiring Manager: Dept. Admin or Div Mgr. / HR Code:
Hiring Authority: Contact person for recruitment purposes
Hiring Authority Contact Information: Phone: Fax: Email:
COMPLETE THIS SECTION FOR ALL REQUESTS
Required Pre-UPRT Process Stakeholder Approvals
All approvals must be obtained via signature on the UPRT request form or via email. If applicable, all documented approvals MUST be
uploaded to BCAP.
A.  Triad:
Signature: DIV CHIEF______Print Name: ______Date: ______
Physician/Clinical Leader
(Physician Practice Lead)
Signature: _DEPT ADMINISTRATOR ______Print Name: ______Date: ______
Administrative Leader
(Practice Manager)
Signature: ______DEPT CHAIR ______Print Name: ______Date: ______
University Department Leader
(Chair)
THE TRIAD MEMBERS MUST BE AVAILABLE TO PRESENT THIS REQUEST TO UPRT
B.  VP Operations:
Signature: ______Print Name: Rebecca Zehngut Date: ______
C.  Chief Clinical Affairs Officer:
Signature: ______Print Name: Dr. Pradeep Kadambi Date: ______
D.  Hospital Leadership (if the request is for a hospital-based position):
Signature: ______Print Name: ______Date: ______
E.  COO B-UMG:
Signature: ______Print Name: Jeff Buehrle Date: ______
F.  Other: This would be when the candidate is going to have appointments in 2 departments for now.
Signature: ______Print Name: ______Date: ______
COMPLETE THIS SECTION FOR ALL REQUESTS
Required Final Pre-UPRT Process Approvals
All approvals must be obtained via signature on the UPRT request form or via email. If applicable, all documented approvals MUST be
uploaded to BCAP.
A.  Dean for the College of Medicine:
Signature: ______Print Name: Dr. Charles Cairns Date: ______
B.  VP Operations Arizona: (if the request is for a hospital based position)
Signature: ______Print Name: Joan Thiel Date: ______
C.  CEO B—UMG:
Signature: ______Print Name: Tom Dickson Date: ______
FOR UPRT USE ONLY
Supporting Documentation Attached: (Request will be returned if appropriate paperwork is not included in the request) (See UPRT policy for list of appropriate documents for type of request)
Pro Forma (For New and Replacement Positions Only)
FMV (For New and Replacement Positions and for Existing Employees who Have a Change in Total Compensation)
Productivity/Funding Tool (For New and Replacement Positions Only)
Request for Change Effort and Funding (For Existing Employees Only)
DRF/T (For Phoenix Positions Only)
UPRT Review Date: / UPRT Recommendation:
AMC Review Date: / AMC Decision:

UPRT Approval Form 1/5/2016

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