UI Hospital ID Badge Authorization Form In order to receive a Hospital ID badge, you will need to bring this authorization form, completed and signed, along with a valid iCard or State ID to the Hospital’s ID office located on the 3rd Floor of the Westside Research Office Building (WROB) at 1747 West Roosevelt Road, which is across the street from the Mile Square Urgent Care Center. To schedule an appointment outside of regular ID Office hours, please call extension 5-2230. ID OFFICE HOURS Monday Tuesday Wednesday Thursday Friday
8:00 am 8:00 am 8:00 am 8:00 am 8:00 am
-
4:00 pm 4:00 pm 4:00 pm 4:00 pm 11:00am
AND
1:00 pm
-
3:00 pm
NAME: UIN: CREDENTIALS: POSITION TITLE: DIRECT PATIENT CARE within Maternal/Child Divisions? YES
NO
[ ] Academic Professional Agency Attending, Fellow, Resident Volunteer
STATUS: [ ] Civil Service [ ] Extra Help Student UIC Student non-UIC
HOSPITAL DEPARTMENT: _____ ________________________ ID Expiration Date (e.g. clinical rotation end date):
________
The individual above is currently serving the University of Illinois Hospital & Health Sciences System in the status checked above. This serves as authorization to provide the employee with a Hospital ID badge. I certify that the individual listed above has complied with all requirements of the Hospital and University to work, observe or provide patient care related services for the Hospital and/or Clinics.
Authorizer’s Name & Title: Phone/Ext.
Please Print Authorizer’s Department: Please Print Authorizer’s Signature: _
Date
Please refer to UIH Hospital Policy EC 3.11 for more information regarding Hospital ID requirements.
