Physician – 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. Complete the HIPAA Security Training Program. Please read: HIPAA Self Study Guide
6. 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 LA General 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
7. 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
8. 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
9. For Patient Controlled Analgesia Privileges (if applicable):
   Please read: Patient Controlled Analgesia
   Complete and submit: Patient Controlled Analgesia Exam

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