UWHC Departmental Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (Graduate Medical Education) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Resident Use of Legal Name, Name Changes, and Credentials
Policy Number: 43.23
Effective Date: April 15, 2015
Chapter: Graduate Medical Education
The purpose of this policy is to set a standard regarding the use of a resident’s legal name for all
purposes at UWHC. The goal is to align with the standards and regulations related to names and name
changes at the United States Social Security Administration (SSA), National Plan and Provider
Enumeration System (NPPES), the Centers for Medicare and Medicaid Services (CMS), the Drug
Enforcement Administration (DEA), the WI Department of Safety and Professional Services (DSPS) and
other statutes, rules and regulations. It is also to prevent confusion within UW Health when different
names are used other than the legal name.
II. PERSONS AFFECTED
This policy applies to all Graduate Medical Education (GME) programs sponsored by the University of
Wisconsin Hospital and Clinics (UWHC).
A. Resident is intended to include all residents and fellows in ACGME accredited training programs.
B. Program(s) will refer to ACGME-accredited program(s).
C. Legal name: the name a resident is known by the United States Social Security Administration.
A. All residents will use their legal name for all purposes at UW Health including but not limited to:
employment and training documentation, computer systems, medical documentation, lab coats,
hospital ID, and all other registration, certification, and licensure.
B. Name changes will only be recognized at UWHC following the change of the legal name with the
Social Security Administration.
C. Credentials: Your highest clinical degree will be included on your badge. Degrees of M.B.B.S,
M.B., or B.Ch may be indicated as M.D. to ease patient confusion. Your actual degree will be
listed on your completion certificate. Advanced degrees of M.P.H, Ph.D., etc. may be included if
they directly relate to your position.
A. Use of Legal Name
1. A resident’s legal name will be verified by viewing the Social Security Administration card or
passport at the time of hire.
2. In the case that multiple names have been used during the application and employment
process, the legal name will be the one used by UW Health.
B. Name changes
1. Proof of a name change will be accepted by UWHC upon presentation to the GME Office of a
Social Security document with the new name along with the documents presented to Social
Security for the change. Acceptable documents include: marriage certificate, divorce
decree, or court order approving a name change.
2. After satisfactory review of the required documents, the GME Office will notify the appropriate
UW Health departments regarding the resident name change.
3. The resident will be responsible for all other notifications and verifications. UWHC is
particularly concerned about NPPES, DEA and the WI DSPS. They should be completed
within 30 days of the change.
4. If the resident is not licensed at the time of the name change, the WI DSPS will require proof
of a name change at the time of licensure if the credentials presented are not in the same
name as the application.
This policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made
for the purpose of inducing any person to become or remain an employee of UWHC, and should not be
considered "promises" or as granting "property" rights. UWHC may add to, subtract from and/or modify
this Policy at any time. Nothing contained in this Policy impairs the right of a non-represented employee
or UWHC to terminate the employment relationship at-will.
UWHC 1.30 Photo Identification Badge and Security Access Systems
ACGME Institutional Requirements, www.acgme.org
ACGME Policies and Procedures Manual, www.acgme.org
Social Security Administration Website, www.ssa.gov
National Plan & Provider Enumeration System (NPPES), nppes.cms.hhs.gov/NPPES/Welcome.do
WI Department of Safety and Professional Services (DSPS), dsps.wisconsin.gov/Home
Drug Enforcement Association (DEA), www.deadiversion.usdoj.gov
Name change procedure for Dane County WI, www.countyofdane.com
Sr. Management Sponsor: Susan Goelzer, MD, Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Affairs
Review/Approval Committee: Graduate Medical Education Committee
Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education
Previous Revision Date: 4/15/2015
Next Revision Due: 4/15/2018 (3 years after effective date)