MEDICAL COLLEGE OF GEORGIA - HOSPITAL AND CLINICS
GRADUATE MEDICAL EDUCATION DATA SHEET
The hospital is required to submit the following information to the Centers for Medicare & Medicaid Services..
Please print clearly and return to Hospital Financial Management, AE 2057.
		Medical/Dental School	
     		     	
Name		Name of School
     		     	
Social Security Number		City and State, or Country if not USA
     		     		     	
MCG Residency Program Name		Graduation Date (Month/Day/Year)		Degree
     		     	
Date entered MCG Residency		ECFMG Certification Date (if Foreign Medical School Graduate)
Please list any previous Internship, Residency, or Fellowship Training in an accredited program within the USA.
	From	To
	Month/Year	Month/Year	Program Name	Hospital	City/State
     		     		     		     		     	
     		     		     		     		     	
     		     		     		     		     	
     		     		     		     		     	
     		     		     		     		     	
Please identify any time lapse between your graduation from medical school and the date you entered MCG's residency program, if you have not included it above in a previous residency program.
	From	To
	Month/Year	Month/Year	Private practice, foreign residency program, non-medical work experience, etc.
     		     		     	
     		     		     	
     		     		     	
     		     		     	
     		     		     	
		     	
Signature		Date