Mid-Level Reappointment Forms

Mid-Level Reappointment Forms

header-title-decorationMid-Level Reappointment Forms

  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