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LLUMC Medical Staff Administration - Forms

Application Documents and Forms

The following application and forms are PDF documents that require Adobe Reader. All initial application packets for LLUMC and/or LLUBMC must be accompanied with the appropriate privilege form(s) printed from this site.

Application:

Initial application packet* (PDF) (743KB)
Contains the following documents:

  • Required Items Checklist
  • Loma Linda University Related Facilities Initial application
  • Addendums A and B
  • Radiography/Fluoroscopy Certification form
  • Laser Certification form
  • HIPAA Compliance Acknowledgment Agreement
  • MediCare Penalty Acknowledgment Statement
  • DEA Waiver form
  • IS Computer Access form

*This packet cannot be submitted electronically. You must print this application packet and complete it manually with black ink only.

Privilege Delineation Forms for Physicians & Dentists (LLUMC & LLUBMC):

LLUMC:

Anesthesiology Pathology & Lab
Cardiovascular & Thoracic Surgery Orthopaedic Surgery
Dermatology Pediatrics
Emergency Medicine Pediatric Surgery
Family Medicine Physical Medicine & Rehab
General Surgery Plastic & Reconstructive Surgery
Head & Neck Surgery Podiatry
Hospital Dentistry Preventive Medicine
Medicine Psychiatry
Neurology Radiation Medicine
Neurosurgery Radiology
Obstetrics & Gynecology Urology
Ophthalmology Vascular Surgery
Oral & Maxillofacial Surgery  

LLUBMC:

Primary Care
Psychiatry
Psychiatry-Anesthesiology

Sedation tests (if requesting moderate or deep sedation for LLUMC only):

The following study guides are provided for physicians eligible to apply for either moderate or deep sedation. The study guides are approximately 75 pages, so you may consider printing only the test and reviewing the appropriate study guide online.

Once the test has been completed, fax only the test pages to Medical Staff Administration at (909) 558-6053 or extension 66053. A certificate will be issued for the sedation privilege(s) upon successfully passing the test(s). Your application will be processed without the certificate, but the privilege to administer sedation will be withheld until the certificate is issued. Please ensure all information is completed at the top of the test(s).

Moderate Sedation

Moderate (P.U.R.P.L.E.) Sedation Test
Moderate (P.U.R.P.L.E.) Study Guide and Test

Deep Sedation

Deep Sedation Test
Deep Sedation Study Guide and Test

Practice Privilege/Job Description Forms for Allied Health Professionals (AHP) (LLUMC & LLUBMC):

LLUMC:

Audiologist
(Job description)
Physician Assistant (PA)
(Practice privileges)
Perfusionist
(Job description)
Sleep Disorders
(Job description)
Clinical Psychologist
(Practice privileges)
Speech-Language Pathologist
(Practice privileges)
Optometrist
(Job description)
Nurse Practitioner (NP)
(Standardized procedure)
Physician Assistant for Neurosurgery
(Practice privileges)
Physician Assistant for Cardiothoracic Surgery
(Practice privileges)

LLUBMC:

Licensed Clinical Social Worker (LCSW)
(Practice privileges)
Psychologist
(Practice privileges)
Marriage, Family Therapist (MFT)
(Practice privileges)