Mid-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