Prior to completing this form, please review UAMS COM GMEC 3.300 Moonlighting Policy. This form must be filled out by either the Program Director or Program Coordinator.
In order to complete this process, you will need to:
- Download the Resident/Fellow Acknowledgment Form, obtain signatures and upload the signed form.
- You must contact the Senior Director, Provider Claims Management at JSmith5@uams.edu to ensure there are no concerns related to resident’s/fellow’s liability insurance coverage for this moonlighting activity. Upload email correspondence AND documented proof of one of the following:
- Individual liability of insurance (UAMS liability insurance does NOT cover external moonlighting activities.)
- Verification of liability insurance coverage from outside employer. Must be on letterhead.
- Certificate of liability coverage from outside employer.
- For internal moonlighting requests only, upload documentation showing approval from department business administrator or their designee for the requested moonlighting activity.
H1B Visa holders: Moonlighting activities may require an amendment to visa status. Prior to submitting request, please contact UAMS Immigration Services at askImmigration@uams.edu to inquire about the process.
Residents and fellows are NOT authorized to begin moonlighting until Program Director has received approval from the Designated Institutional Official. The GME Office will provide confirmation of the approval to the program.