Out Of Clinic Notification Form

DEPARTMENT OF NEUROLOGY
OUT OF CLINIC NOTIFICATION FORM

To ensure continuity of patient care, avoid clinic reschedules, and allow you to fully disconnect from clinical duties during your time out of the office, please submit this form 90 days prior to your leave to ensure appropriate parties are informed and necessary actions are taken.

HOW-TO Instructions for closing Epic In Baskets - Click HERE.

NAME:*

Enter your email if you would like to receive a confirmation email.

FIRST DATE OUT OF OFFICE: *

DATE RETURNING TO THE OFFICE:*

Prefer to close*

Full Day Morning Only Afternoon Only

Please list dates that you prefer to close the morning or afternoon session only.

I will confirm that my clinics are closed correctly for these dates prior to my leave.

I will confirm that there are no pending patient needs in my Epic In Basket prior to my leave.

In case of urgent patient needs during my absence, my Epic In Basket is forwarded to the following covering provider:*

Physician on call for DocLine for my section Other covering provider:

If fewer than 90 days’ notice was provided for clinic closures, makeup clinic dates may be scheduled for me on the following date(s):*

Not applicable Select Dates

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