Attending Staff Office
Reappointment 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.
Reappointment Cover Page
2. Read and Complete
Reappointment Form
3. Forward letter to your peer or have the ASO distribute the letter.
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 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
6. For Moderate Sedation Privileges: (if applicable)
Please Read:
   Moderate Sedation Learning Module
   Moderate Sedation Policy
   Moderate Sedation Answer Sheet
Complete and Submit:
   Moderate Sedation Request Form
   Moderate Sedation Exam
7. For Brain Death Privileges: (if applicable)
Please Read:
   Brain Death Syllabus
   Brain Death Policy & Procedure
   Brain Death Declaration Form-Check List
   Brain Death Answer Sheet
Complete and Submit:
   Brain Death Request Form
   Brain Death Exam

These forms are available as PDF's. To download the free Adobe Acrobat Reader click here.

IF YOU HAVE REACHED THIS POINT, YOU HAVE COMPLETED YOUR REAPPOINTMENT 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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