Dr. Spellberg
LACUSC Joint Commission
My Wellness Patient Portal
Therapy dog and a patient experience life in 3D.
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Physician - Initial Appointment 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:

    Application Cover Page

  2. Read and Complete:

    Application Form
    Work History Form

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

    Peer Reference Letter

  4. Read and sign:

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

  5. Complete the HIPAA Security Training Program.  Please read:

    HIPAA Self Study Guide

  6. Complete the Code of Conduct Awareness Training Program.  Complete and submit:

    Compliance Awareness Training (For new workforce only)
    Compliance Update Training

  7. Complete the Central Line Training Program.  Read, complete and submit:

    Memorandum
    Central Line Associated Blood Stream Infection Education Module

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

    Anesthesiology
    Dentistry
    Dermatology
    Emergency Medicine
    Employee Health/Occupational Medicine
    Family Medicine
    Medical Education
    Medicine for Comprehensive Health Centers
    Medicine for LACUSC Medical Center
    Neurology
    Neurosurgery
    Obstetrics and Gynecology
    Obstetrics and Gynecology (Office Practice Procedures)
    Ophthalmology
    Orthopedics
    Otolaryngology
    Pathology
    Pediatrics
    Pharmacist for Hepatitis-C Clinic
    Podiatry
    Psychiatry
    Radiation Oncology
    Radiology
    Surgery
    Urology

  9. For Moderate Sedation Privileges (if applicable):

    Please read:

           Moderate Sedation Learning Module
           Moderate Sedation Policy

    Complete and submit:

           Moderate Sedation Request Form
           Moderate Sedation Request Exam
           Moderate Sedation Request Answer Sheet

  10. For Brain Death Privileges (if applicable):

    Please read:

           Brain Death Syllabus
           Brain Death Policy and Procedure
           Brain Death Declaration Form Checklist

    Complete and submit:

           Brain Death Request Form
           Brain Death Exam
           Brain Death Answer Sheet

  11. For Patient Controlled Analgesia Privileges (if applicable):

    Please read:

           Patient Controlled Analgesia

    Complete and submit:

           Patient Controlled Analgesia Exam

  12. Proctoring Forms:

    General
    Anesthesiology
    Dentistry
    Medicine
    Orthopedics
    Pathology
    Pediatrics
    Psychiatry
    Radiology
    Surgery

  13. Clinical Systems Access Applications:

    User Access request
    Agreement for Acceptable Use
    USB Drive Request Form

  14. Patient Safety Education Training:

    Patient Safety Education Training


If you need to apply for NPI NUMBER, click here.
 

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

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