UTP Acquisition Request Form

To initiate HR involvement in the acquisition process, please complete this form and submit the following items to HRUTP@uth.tmc.edu:

Please direct questions or concerns to the HR UT Physicians Team at 832.325.7671 or HRUTP@uth.tmc.edu.

Requester Information

Name:

Medical school department:

Email:

Phone:

Entity Information

Name of entity to be acquired:

Physical address of entity to be acquired:

Anticipated Go Live Date of Acquisition:

Number of employees:

Will any of the physician positions require a faculty appointment to work at their assigned location?

Number of providers:

Number of advanced care providers:

Number of locations:

Comments: