Attending Staff Office
Initial Appointment Forms
(PLEASE PRINT AND FILL OUT)
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
3. Forward letters to your peers or have the ASO distribute them.
Peer Reference Letter
4. 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
5. Complete the HIPAA Security Training Program:
Please read:
     HIPAA Self Study Guide
Complete exam:
     HIPAA Assessment Exam
Complete and submit:
     HIPAA Answer Sheet
6. Complete the Code of Conduct Awareness Training Program:
Complete and submit:
     Compliance Awareness Training (For new workforce only)
     Compliance Update Training
7. Complete the Central Line Training Program:
Read, complete and submit:
     Memorandum
     Central Line Associated Blood Stream Infection Education Module
8. Select your Privilege Form
Please Note:  When requesting privileges for more than one department you need to fill out only one application.
Anesthesiology
Cardiothoracic Surgery
Dentistry
Dermatology
Emergency Medicine
Employee Health/Occupational Medicine
Family Medicine
Medicine For Comprehensive Health Centers
Medicine For LACUSC Healthcare Network
Neurology
Neurosurgery
Obstetrics And Gynecology
Obstetrics And Gynecology (Office Practice Procedures)
Ophthalmology
Orthopedics
Otolaryngology
Pathology
Pediatrics
Psychiatry
Psychiatry Special Form
Radiation Oncology
Radiology
Surgery
Urology
9. For Moderate Sedation Privileges: (if applicable)
Please read:
     Moderate Sedation Learning Module
     Moderate Sedation Policy
Complete and submit:
    Moderate Sedation Request Form
    Moderate Sedation Exam
    Moderate Sedation Answer Sheet
10. For Brain Death Privileges: (if applicable)
Please read:
    Brain Death Syllabus
    Brain Death Policy & Procedure
    Brain Death Declaration Form-Check List
Complete and submit:
    Brain Death Request Form
    Brain Death Exam
    Brain Death Answer Sheet
11.  Proctoring Forms:
    General
    Anesthesiology
    Dentistry
    Medicine
    Orthopedics
    Pathology
    Pediatrics
    Psychiatry
    Radiology
    Surgery
12.  Clinical Systems Access Applications:
    User Access request
    Agreement for Acceptable Use
13.  Patient Safety Education Training:
    Patient Safety Education Training
 
These forms are available as PDF's. To download the free Adobe Acrobat Reader click here.
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

1200 N. State St. Clinic Tower, Room 2B300
Los Angeles, CA 90033


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