Application Documents and Forms

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

Privilege Delineation Forms | Moderate Sediation | Deep Sediation


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

Privilege Delineation Forms (LLUMC - LLUCH - LLUBMC)

Moderate Sedation

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).

Deep Sedation