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Mid-Level Provider - Reappointment Forms (please print and fill out)

  1. Read First.  Please utilize the included checklist to ensure that you are returning all of the required documents:

    Reappointment Cover Page

  2. Read and Complete:

    Reappointment Form

  3. Forward letter to your peers or have the ASO distribute them:

    Peer Reference Letter

  4. Read and sign:

    a.  
    EMTALA Regulations Statement
            ⇒
    Read the EMTALA Reference Guide
    b.  
    List of Hospital Affiliations
    c.  
    Tuberculosis Screening
    d.  
    Data Security Acknowledgment Statement
            ⇒
    Read the Data Security Policy

  5. Select your Privilege Form.  Please note:  When requesting privileges for more than one department, you need to fill out one application only.

    Nurse Anesthetist (CRNA)

    Nurse Practitioner - Emergency Medicine
    Nurse Practitioner - Medicine
    Nurse Practitioner - Neurosurgery
    Nurse Practitioner - Obstetrics and Gynecology
    Nurse Practitioner - Ophthalmology
    Nurse Practitioner - Orthopedic Surgery
    Nurse Practitioner - Pediatrics
    Nurse Practitioner - Psychiatry
    Nurse Practitioner - Radiation Oncology
    Nurse Practitioner - Surgery
    Nurse Practitioner - Urology

    Optometrist - Ophthalmology

    Pharmacist - Ambulatory Care
    Pharmacist - Hepatitis-C Clinic
    Pharmacist - Inpatient AntiCoagulation

    Physician Assistant - Dermatology
    Physician Assistant - Emergency Medicine
    Physician Assistant - Medicine
    Physician Assistant - Medicine Rand Schrader Clinic - 5P21
    Physician Assistant - Neurology
    Physician Assistant - Neurosurgery
    Physician Assistant - Orthopaedics
    Physician Assistant - Pediatrics
    Physician Assistant - Radiology
    Physician Assistant - Surgery
    Physician Assistant - Teaching Only
    Physician Assistant - Urology

  6. HIPAA Guide and Quiz:

    Please read, complete quiz and submit:

           HIPAA Guide and Quiz
           
  7. Essential Elements of Patient Safety:

    Please read, complete questionnaire and submit:

           Essential Elements of Patient Safety

  8. Compliance Awareness Training:

    Please read:

           Compliance Awareness Training


IF YOU HAVE REACHED THIS POINT, YOU HAVE COMPLETED YOUR REAPPOINTMENT PACKET.  Submit your packet to the Attending Staff Office:

       Attending Staff Office
       1200 N. State St.
       Clinic Tower, Room 2B300
       Los Angeles, CA 90033