Medical Staff Services Department

Contact Us

Kristi Graham, BA, CPCS
Director of Medical Staff Services
[email protected]
(714) 524-4802

To obtain verification letters for Medical Staff, please visit our website here.

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Medical Staff Request for Application

Thank you for your inquiry indicating your interest in applying for medical staff appointment and clinical privileges at Placentia-Linda Hospital.

The following are threshold eligibility criteria for appointment to the Medical Staff:

  1. A current, active professional license to practice in CA, which is without restriction or limitation and no record of revocation, suspension or probation, restriction or limitation (of licensure in any state) within the past ten years. Exception is permissible for administrative reasons not related to crimes or professional competence or conduct.*
  2. Current, unrestricted federal DEA registration (if applicable).
  3. Satisfactory completion of, or current enrollment in, an accredited postgraduate residency training program in the specialty in which you are seeking clinical privileges.
  4. Board certification by the appropriate specialty Board (American Board of Medical Specialties, the American Osteopathic Association Board of Specialists, the American Board of Oral and Maxillofacial Surgery, the American Board of Podiatric Surgery, or the American Board of Podiatric Orthopedic and Primary Podiatric Medicine) or proof that you have met/or will meet the requirements for examination for certification by the appropriate specialty Board.
  5. Current, valid professional liability insurance coverage with a qualified California carrier in the following form and amounts $1,000,000/$3,000,000 and which covers all clinical privileges that you may request.
  6. Practitioner is not currently excluded, suspended, debarred or otherwise ineligible to participate in Federal health care programs.
  7. No history of felony conviction for or withhold of felony adjudication for a crime against a person (includes a no contest plea).
  8. Any felony conviction within the past ten years.*
  9. No pending charges and no record of convictions within the past ten years, or, withhold of adjudication for, or plea of guilty or no contest, deferred prosecution or pre-trial intervention arrangement to, a felony, or misdemeanor related to (a) the practice of your profession; (b) other health care matters; (c) third-party reimbursement; (d) violence; or (e) the use, prescription distribution, or furnishing of DEA scheduled drugs (Schedules I through V) *.
  10. Within past ten years, medical staff membership and clinical privileges have been granted and maintained in good standing without any adverse action of any kind, whether voluntary or involuntary, including but not limited to (11):
  11. No record of denial, revocation, termination, suspension not related to administrative issues, reduction, loss, condition, restriction, limitation, involuntary resignation or relinquishment, voluntary resignation, relinquishment, or leave of absence after notice of investigation or discipline regarding appointment, membership, or clinical privileges in the same or similar specialty at this or any other hospital or healthcare facility or entity. This restriction does not apply to adverse actions for administrative reasons. Reinstatement of unrestricted privileges or appointment within past ten years does not negate criteria. *

*Occurrences greater than 10 years past require practitioner to submit written explanatory summary and authorization for hospital to obtain further information from involved entities in addition to a completed application for appointment.

Please be advised that the hospital has entered into exclusive arrangements for the following services and is not accepting applications in these specialties: Anesthesiology, Emergency Medicine, Pathology, and Radiology, unless you are affiliated with the contracted group.

Please complete the enclosed Request for Application documents in their entirety and return them with copies of all required supporting documentation within thirty (30) days from receipt of “Request for Application.”

Upon receipt of the complete and accurate Request for Application, a determination will be made as to whether an Application for Medical Staff Appointment and Clinical Privileges may be extended to you. You will be notified of that determination, and if eligible, you will receive an application form as well as other specific information required for appointment and clinical privileges.

Thank you for your interest in Placentia-Linda Hospital. If I can be of any further assistance, please contact me at 714-524-4802.

Medical Staff (Physicians)

Download Pre-Application Form

Allied Health (Physician Assistants and Nurse Practitioners)

Download Pre-Application Form