Request Pre-Application

Thank you for your interest in becoming a member of Touro's Medical Staff. Please complete this form to receive an application packet.

  • Please enter your first name.
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  • Office Information
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  • Please enter your office's address.
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  • Please enter your office's contact name.
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  • Additional Information
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  • Please enter a date.
  • Please enter your Current LA State License Number.
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  • Please enter your NPI.
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  • Please list your current primary facility.
  • ACTIVE STAFF: Regularly admit, or are otherwise regularly involved in the care of patients in this facility (a minimum of eleven [11] patient contacts per year of appointment) or are regularly involved in Medical Staff functions, as determined by the Medical Staff. Accept on-call coverage for emergency care services within his/her Medical Staff Division as specified by the requirements of the assigned Medical Staff Division. COURTESY STAFF: Admitting privileges and performance of procedures are restricted to a maximum of eleven [11] patient contacts per year of appointment. AFFILIATE STAFF: Perform outpatient preadmission and history and physical exam, order noninvasive outpatient diagnostic tests and services, visit patients in the hospital, view only medical record privileges, and observe diagnostic or surgical procedures with the approval of the attending physician or surgeon. Cross-covering physician not required as no clinical privileges are granted.
    Please make a selection.
  • Please list your specialty/specialties.
  • You are required to have a Cross Covering Physician. This physician must be a member of Touro’s Medical Staff or currently applying for Medical Staff appointment. Your cross covering physician should also have the same type of privileges you are requesting.
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  • For example, to provide coverage for a physician on Touro’s active staff, to join a group associated with Touro Infirmary, or relocating to the New Orleans/Uptown area.
    Please tell us why you would like to become a member.