{"id":543,"date":"2020-07-09T10:05:55","date_gmt":"2020-07-09T10:05:55","guid":{"rendered":"https:\/\/dhs.lacounty.gov\/lageneral\/mid-level-provider-initial-appointment-forms\/"},"modified":"2023-04-24T12:45:40","modified_gmt":"2023-04-24T19:45:40","slug":"mid-level-provider-initial-appointment-forms","status":"publish","type":"page","link":"https:\/\/dhs.lacounty.gov\/lageneral\/who-we-are\/attending-staff\/credentialing-applications\/mid-level-provider-initial-appointment-forms\/","title":{"rendered":"Mid-Level Initial Appointment Forms"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text]<\/p>\n

\n
\n
\n
    \n
  1. Read First. \u00a0Please utilize the included checklist to ensure that you are returning all of the required documents: Application Cover Page<\/a><\/li>\n
  2. Read and Complete: Application Form<\/a>
    \n    Work History Form<\/a><\/li>\n
  3. Forward letter to your peers or have the ASO distribute them: Peer Reference Letter<\/a><\/li>\n
  4. Read and sign:
    \na. \u00a0    EMTALA Regulations Statement<\/a>
    \n\u21d2\u00a0    Read the EMTALA Reference Guide<\/a>
    \nb. \u00a0    Tuberculosis Screening Attestation<\/a>
    \nc. \u00a0    List of Hospital Affiliations<\/a>
    \nd. \u00a0    Data Security Acknowledgment Statement<\/a>
    \n\u21d2\u00a0    Read the Data Security Policy<\/a>
    \ne. \u00a0    Affirmative Statement<\/a><\/li>\n
  5. Complete the HIPAA Security Training Program. \u00a0Please read: HIPAA Self Study Guide<\/a><\/li>\n
  6. Complete the Code of Conduct Awareness Training Program.
    \nComplete and submit:     Compliance Awareness Training (For new workforce only)<\/a>
    \n    Compliance Update Training<\/a><\/li>\n
  7. Select your Privilege Form. \u00a0Please note: \u00a0When requesting privileges for more than one department, you need to fill out one application only.
    \n    Nurse Anesthetist (CRNA)<\/a>
    \n    Nurse Practitioner – Emergency Medicine<\/a>
    \n    Nurse Practitioner – Medicine<\/a>
    \n    Nurse Practitioner – Neurosurgery<\/a>
    \n    Nurse Practitioner – Obstetrics and Gynecology<\/a>
    \n    Nurse Practitioner – Ophthalmology<\/a>
    \n    Nurse Practitioner – Orthopedic Surgery<\/a>
    \n    Nurse Practitioner – Pediatrics<\/a>
    \n    Nurse Practitioner – Psychiatry<\/a>
    \n    Nurse Practitioner – Radiation Oncology<\/a>
    \n    Nurse Practitioner – Surgery<\/a>
    \n    Nurse Practitioner – Urology<\/a>
    \n    Optometrist – Ophthalmology \u00a0<\/a>
    \n    Pharmacist – Ambulatory Care<\/a>
    \n    Pharmacist – Hepatitis-C Clinic<\/a>
    \n    Pharmacist – Inpatient AntiCoagulation<\/a>
    \n    Physician Assistant – Dermatology<\/a>
    \n    Physician Assistant – Emergency Medicine<\/a>
    \n    Physician Assistant – Medicine<\/a>
    \n    Physician Assistant – Medicine Rand Schrader Clinic – 5P21<\/a>
    \n    Physician Assistant – Neurology<\/a>
    \n    Physician Assistant – Neurosurgery<\/a>
    \n    Physician Assistant – Orthopaedics<\/a>
    \n    Physician Assistant – Pediatrics<\/a>
    \n    Physician Assistant – Radiology<\/a>
    \n    Physician Assistant – Surgery<\/a>
    \n    Physician Assistant – Teaching Only<\/a>
    \n    Physician Assistant – Urology<\/a><\/li>\n
  8. Proctoring Forms:
    \n    General<\/a>
    \n    Anesthesiology<\/a>
    \n    Dentistry<\/a>
    \n    Medicine<\/a>
    \n    Orthopedics<\/a>
    \n    Pathology<\/a>
    \n    Pediatrics<\/a>
    \n    Psychiatry<\/a>
    \n    Radiology<\/a>
    \n    Surgery<\/a><\/li>\n
  9. Clinical Systems Access Applications:
    \n    User Access request<\/a>
    \n    Agreement for Acceptable Use<\/a>
    \n    USB Drive Request Form<\/a><\/li>\n
  10. Patient Safety Education Training:
    \n    Patient Safety Education Training<\/a><\/li>\n
  11. Delegation of Service Agreement (for Physician Assistant ONLY)<\/a><\/li>\n<\/ol>\n

    If you need to apply for <\/span>NPI NUMBER, <\/span><\/strong><\/span>click here<\/span><\/span><\/a>.<\/span><\/span>
    \n<\/span><\/p>\n

    IF YOU HAVE REACHED THIS POINT, YOU HAVE COMPLETED YOUR APPOINTMENT PACKET. Submit your packet to the Attending Staff Office:<\/span><\/strong><\/span><\/p>\n

    Attending Staff Office
    1200 N. State St.
    \nClinic Tower, Room 2B300
    \nLos Angeles, CA 90033\u00a0<\/span><\/span><\/p>\n<\/div>\n<\/div>\n

     <\/p>\n<\/div>\n

    [\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"

    [vc_row][vc_column][vc_column_text] Read First. \u00a0Please 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. \u00a0EMTALA Regulations Statement \u21d2\u00a0Read the EMTALA Reference […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":300,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/template-subsite-basic-page.php","meta":{"_oasis_is_in_workflow":0,"_oasis_original":0,"_monsterinsights_skip_tracking":false,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[1],"tags":[],"class_list":["post-543","page","type-page","status-publish","hentry","category-uncategorized"],"yoast_head":"\nMid-Level Initial Appointment Forms - LA General Medical Center<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/dhs.lacounty.gov\/lageneral\/who-we-are\/attending-staff\/credentialing-applications\/mid-level-provider-initial-appointment-forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Mid-Level Initial Appointment Forms - 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