Physician – Initial Appointment Forms
- Read First. Please utilize the included checklist to ensure that you are returning all of the required documents:Application Cover Page
- Read and Complete:Application Form
Work History Form - Forward letter to your peers or have the ASO distribute them:Peer Reference Letter
- Read and sign:a. Medicare Acknowledgment Statement
b. EMTALA Regulations Statement
⇒ Read the EMTALA Reference Guide
c. Tuberculosis Screening Attestation
d. List of Hospital Affiliations
e. Data Security Acknowledgment Statement
⇒ Read the Data Security Policy
f. Affirmative Statement - Complete the HIPAA Security Training Program. Please read:HIPAA Self Study Guide
- Complete the Code of Conduct Awareness Training Program.
Complete and submit:Compliance Awareness Training (For new workforce only)
Compliance Update Training - Complete the Central Line Training Program. Read, complete and submit:Memorandum
Central Line Associated Blood Stream Infection Education Module - 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 - 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 - 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 - For Patient Controlled Analgesia Privileges (if applicable):
Please read: Patient Controlled Analgesia
Complete and submit: Patient Controlled Analgesia Exam - Proctoring Forms: General
Anesthesiology
Dentistry
Medicine
Orthopedics
Pathology
Pediatrics
Psychiatry
Radiology
Surgery - Clinical Systems Access Applications:User Access request
Agreement for Acceptable Use
USB Drive Request Form - Patient Safety Education Training:Patient Safety Education Training
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
