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 – UrologyOptometrist – OphthalmologyPharmacist – Ambulatory Care
    Pharmacist – Hepatitis-C Clinic
    Pharmacist – Inpatient AntiCoagulationPhysician 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

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