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.


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
  • Tuberculosis Screening Questionnaire
  • Facility specific department/service Privilege form(s) [downloaded separtely]
  • Moderate/Deep Sedation Test (LLUMC only)
  • 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):


Administrative Signature Form Ophthalmology
Adult Intensivist Oral & Maxillofacial Surgery
Anesthesiology Pathology & Lab
Cardiovascular & Thoracic Surgery Orthopaedic Surgery
Dermatology Pediatrics
Emergency Medicine Pediatric Surgery
Endovascular Surgical Neuroradiology
(Supplement to Radiology & Neurosurgery Services)
Physical Medicine & Rehab
Family Medicine Plastic & Reconstructive Surgery
General Surgery Podiatry
Head & Neck Surgery Preventive Medicine
Hospital Dentistry Psychiatry
Medicine Radiation Medicine
Neurology Radiology
Neurosurgery Urology
Obstetrics & Gynecology Vascular Surgery

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


(Job description)
Physician Assistant for Orthopaedic Service
(Practice privileges)
Clinical Psychologist
(Practice privileges)
Speech-Language Pathologist
(Practice privileges)
(Job description)
Nurse Practitioner (NP)
(Standardized procedure)
Physician Assistant for Neurosurgery
(Practice privileges)
Physician Assistant for Cardiothoracic Surgery
(Practice privileges)

Physician Assistant for Family Medicine/Urgent Care
(Practice privileges)

Physician Assistant for Head & Neck Surgery
(Practice privileges)

Physician Assistant for Plastic & Reconstructive Surgery
(Practice privileges)

Physician Assistant for Emergency Medicine
(Practice privileges)

Registered Nurse First Assistant
(Practice privileges)

Heart & Surgical Hospital - Vascular Center:

Peripheral Endovascular Interventional Cardiologists
Peripheral Endovascular Interventional Radiologists
Peripheral Endovascular Interventional Procedures for Vascular Surgeons


Administrative Request Form
Primary Care

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

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
Moderate Sedation Study Guide for Physicians ONLY
Moderate Sedation Test for Physicians ONLY

Deep Sedation

Deep Sedation Test
Deep Sedation Study Guide and Test