[DEPAMED] Residency, Fellowship and EXCEL Application Form

Application Form

Department of Advanced Medical Education
Dear Applicants,

Before proceeding with the Online Application Form, kindly compile all the necessary requirements that need to be emailed after completing this online form. Please ensure all documents are in PDF format and follow the file naming convention.

Example:
Surname_FirstName_DocumentName.pdf
DelaCruz_Juan_CurriculumVitae.pdf

Here is the list of minimum requirements:
• Curriculum Vitae
• Letter of Intent with Signature
• Send two (2) Names with Gmail/School Email Address and Viber Number for Character Reference
• Class Ranking
• Transcript of Records
• Medical Diploma
• Certificate of Internship
• Certificate of Residency (for fellowship only)
• Diplomate Certificate (for fellowship only)
• PRC Board Rating
• PRC License Card (Front and Back with Signature in one file)
• PRC Board Certificate
• Updated BLS and ACLS Certificate
• Immunization Record (MMR, Varicella, TDAP, Hepatitis B)
• BIR Form 2303 – Certificate of Registration
• Income Payee’s Sworn Declaration

PLEASE NOTE THAT WE WILL NOT PROCESS YOUR APPLICATION IF YOU DON'T FOLLOW THE CORRECT FILE FORMAT AND NAMING CONVENTION.

Thank you very much!
Date Applied

MonthDayYear
Date
Applying for:*

ResidencyFellowshipEXCEL (Executive Leadership for Physician Trainees)
Residency Program
Fellowship Program
In compliance with the Data Privacy Act of 2012, The Medical City ensures that your information will be kept strictly confidential and only processed, disclosed, or shared upon your consent. Your data will be used exclusively for the purpose of reviewing your application.

Application Form

Educational Background
COLLEGE:
Name of Institution*
Degree*
Date Graduated*
Month and Year
MEDICAL SCHOOL:
Name of Institution*
Degree*
Date Graduated*
Month and Year
POST-GRADUATE INTERNSHIP (HOSPITAL):
Name of Institution*
Date Started*

MonthDayYear
Date Ended*

MonthDayYear
PHILIPPINE MEDICAL LICENSURE EXAMINATION GRADE
Examination Grade*
Date Taken*
Month and Year
RESIDENCY (HOSPITAL):
Name of Institution
Date Started*

MonthDayYear
Date Ended*

MonthDayYear
SPECIALTY BOARD EXAM:
Name of Society
Date Taken*
Month and Year
Where do you intend to practice in the future?*

TMC OrtigasTMC ClarkTMC IloiloTMC PangasinanTMC South LuzonTMC ClinicsOther
Honors or Awards Received
Have you published or presented any medical research paper?*

YesNo
Research Paper Title
In compliance with the Data Privacy Act of 2012, The Medical City ensures that your information will be kept strictly confidential and only processed, disclosed, or shared upon your consent. Your data will be used exclusively for the purpose of reviewing your application.

Application Form

Other Relevant Information
Recommended by:

First NameLast Name
Contact Number
Have you ever been evaluated relative to or for any administrative complaints or disciplinary actions?

YesNo
If YES, please provide details:
Have you ever been convicted of criminal offense?

YesNo
If YES, please provide details:
Have you ever been dismissed, suspended, or placed on probation by any school, hospital, or institution?

YesNo
If YES, please provide details:
Do you have any relatives working in The Medical City?

YesNo
If YES, please give the Name and Department of your relative/s
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Complete Name*

First NameLast Name
Relationship*
Address*
Conctact Number*
In compliance with the Data Privacy Act of 2012, The Medical City ensures that your information will be kept strictly confidential and only processed, disclosed, or shared upon your consent. Your data will be used exclusively for the purpose of reviewing your application.

Application Form

Consent Forms

APPLICANT'S CONSENT AND RELEASE
I, {nameOf}, am applying for a {applyingFor} training program with the Department of Advanced Medical Education (DAM).

I understand that as an applicant, I have the burden of producing adequate information for proper evaluation of my qualifications and for resolving any doubts about my qualifications. I understand that my application will not be processed u ntil it is deemed complete by DAM.

I have the responsibility to keep my application current by informing DAM of any material change or addition to the information I have initially provided to this application of the filing of a lawsuit or other claims against me relating to my competency to practice my Profession. I will provide additional information that may be requested by the organization or its authorized representatives. My failure to provide the information requested, will prevent my application from being evaluated and acted upon.

I attest that the information included in this application is current, complete, accurate, and true. Any misrepresentation, misstatement, or omission from this application, whether intentional or not, may result in an automatic and immediate rejection of my application for appointment.

By applying for the residency/fellowship training program, I hereby:
- Agree to appear for an interview in regard to my application if required;
- Authorize DAM and their representatives to consult with administrators and members of other healthcare facilities/organizations of which I am or have been associated with, or any person who may have information related to my qualifications;
- Agree to provide a signature to assist in verifying my identity and credentials to other institutions;
- Agree that I have disclosed in my application all criminal convictions and any felony charges brought or pending against me. I further authorize DAM and its representatives to request individual, company, firm, corporation or public agency, including law enforcement agencies, to divulge, any criminal records or information, verbal or written, pertaining to me, including information or data received from other sources.
I hereby release from liability to the fullest extent permitted by law all representatives of The Medical City and its Medical/Professional staff for their acts performed and statements made in good faith and without malice within its scope as a review entity. I hereby release from liability any and all third parties who in good faith, and without m alice, provide information to the facility/organization concerning my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics or behaviour or any other matter that might have an effect on my competence, on patient care or on the orderly operation of any hospital or of The Medical City.

I agree to:
- Abide by the bylaws, rules and policies of The Medical City
- Abide by the residency/fellowship rules and regulation and the rules and policies of the department and/or clinical service to which I am assigned
- Adhere to recognized principles governing the practice of medicine, participate in continuing education program which relate, at least in part, granted to me by DAM, and document such participation when requested to do so;
- Observe the highest degree of morality in my relationship with my patients, colleagues and TMC personnel.
- Provide for care for my patients consistent with the standard of practice of my profession, accept committee assignments, accept administrative duties and participate in staffing emergency room service areas in my specialty on a reasonably agreed upon basis if requested to do so;
- Comply with applicable laws, including abstaining from the division of fees or remuneration for referrals under any guise whatsoever;
- Maintain a constructive interest and cooperate in advancing The Medical City as a quality healthcare facility/organization; and;
- Seek consultation by physicians of appropriate clinical experience as needed or requested.
I acknowledge that residency/fellowship training program at DAM are not a right of every licensed professional who makes application for the same.

I understand that:
- My application will be evaluated in accordance with prescribed procedures defined in the residency/fellowship training program.
- All medical staff recommendations relative to my application are subject to the ultimate action of DAM;
- If appointed, my initial appointment shall be provisional for the time period determined by Department of Advanced Medical Education; reappointment remain contingent upon my continued demonstration of professional competence and cooperation, acceptable performance of all responsibilities, as well as the other factors deemed relevant by DAM.
- The provisions of the rules and regulations relating to confidentiality and release from liability are express conditions of my application for residency/fellowship training program.

CONSENT AND AUTHORIZATION FOR PROCESSING OF PERSONAL DATA
We at THE MEDICAL CITY are committed to the protection of your privacy in your engagement with us.

DATA PROCESSING:

We process your personal and sensitive personal information (collectively, “data”) as a prior, current, or former affiliate to ensure that we are meeting our responsibilities and duties as an organization. Information we collect from you may include but is not limited to:
- Resumes that you provide and/or application(s) that you fill out and provide to us;
- Your photo ID;
- General contact information, such as home address, mobile and home numbers, clinic address and phone number, and email;
- Your start date;
- Your job title/s;
- Gender;
- Marital status;
- Date of birth;
- Religious beliefs;
- Health data;
- Biometric data;
- Professional License details;
- Your trainings and certifications – specializations and sub-specializations;
- Your medical society memberships and standings;
- Your engagements and affiliations in hospitals and clinics outside the Company;
- Professional or personal references;
- Criminal, civil, and/or administrative cases against you;
- The contact information of the individual that you list to be first notified in the event of an emergency. This includes phone numbers, addresses, and any other personally identifying information for that individual.
- Company policies and forms signed by you;
- Payroll and/or bank information and other additional direct deposit information for the payment of your professional fees;
- Any monetary raises, bonuses, commissions, overtime rate, salaried rate and/or regular hourly rate, when applicable;
- Your government issued numbers (SSS, TIN, PAG-IBIG, CTC, PTR, Philhealth, PWD), bank account information, and additional direct deposit information;
- Forms that contain any information relating to your status as a stockholder (if applicable) and its related benefits;
- Assessments, evaluations, performance reviews, training completion rates, and training scores;
- Any requested time off, accrued paid time off, tardiness, or requests to leave before the scheduled end of your workday, when applicable;
- Grievances, including complaints made by fellow doctors, employees or patients, corrective actions plan for inappropriate behavior and write-ups;
- Accolades, including recommendations, awards, or other instances of recognition for quality work;
- Letter of resignation, if received by the Company;
- Letter of termination, if given; and
- Other personal details you voluntarily provide to us;
We only process your Personal Data if we have your consent to do so, where we are permitted by law or required to do so, where we have a legal obligation as an organization, for legitimate business purposes, or to protect your vital interests. We may have to process your Personal Data without your consent or knowledge when required by law. We also process your Personal Data to prevent fraud and ensure the security of all aspects of our business.

We use the information that we collect about you to effectively run our business and to help us provide a pleasant, safe, and productive environment for you. We use Personal Data to:
- Accurately process payments due you;
- For processing of your health and non-monetary benefits
- Manage and plan our business;
- For internal accounting;
- Do primary verification of your credentials and analyze your qualifications;
- Process any claims you bring;
- Put you through education or training, if applicable;
- Send out business mailings;
- Conduct professional and peer reviews;
- Handle internal disputes or grievances;
- Generally, comply with applicable law.
We may share your Personal Data to those third-party individuals and entities who assist in fulfilling our responsibilities within the engagement relationship with you or when required to do so by applicable law. These third-party providers help facilitate and manage credentialing within the TMC Network of hospitals and clinics, training and education of residents and fellows, promotions and communications with our patients and clients. For more information, kindly refer to our PRIVACY POLICY FOR DOCTORS.

DATA PROTECTION:

We implement reasonable and appropriate organizational, physical, and technical security measures for the protection of personal data which we collected. These security measures aim to maintain the availability, integrity, and confidentiality of personal data and are intended for the protection of personal data against any accidental or unlawful destruction, alteration, and disclosure, as well as against any other unlawful processing.

I have read and understood this Consent and Authorization for Processing of Personal Data and express my consent for The Medical City to process of my data for the purposes stated above. I understand that my consent does not preclude the existence of other criteria for lawful processing of personal data and does not waive any of my rights under the Data Privacy Act of 2012 and other applicable laws.
I confirm that all details in this application form are accurate and complete. I have not intentionally concealed any information that may affect my application. I acknowledge that any false statements or omissions on my part may result in the rejection of my application or termination of employment if hired. I consent to The Medical City utilizing my information for application processing purposes.
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In compliance with the Data Privacy Act of 2012, The Medical City ensures that your information will be kept strictly confidential and only processed, disclosed, or shared upon your consent. Your data will be used exclusively for the purpose of reviewing your application.
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