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Mid-Level Provider - 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.  
    EMTALA Regulations Statement
            ⇒
    Read the EMTALA Reference Guide
    b.  
    Tuberculosis Screening Attestation
    c.  
    List of Hospital Affiliations
    d.  
    Data Security Acknowledgment Statement
            ⇒
    Read the Data Security Policy
    e.  
    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. 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

  8. Proctoring Forms:

    General
    Anesthesiology
    Dentistry
    Medicine
    Orthopedics
    Pathology
    Pediatrics
    Psychiatry
    Radiology
    Surgery

  9. Clinical Systems Access Applications:

    User Access request
    Agreement for Acceptable Use
    USB Drive Request Form

  10. Patient Safety Education Training:

    Patient Safety Education Training

  11. Delegation of Service Agreement (for Physician Assistant ONLY)


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