Mid-Level Initial Appointment Forms

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