Request Pre-Application

Thank you for your interest in becoming a member of Touro's Medical Staff. Please complete this form to receive a pre-application packet.
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First Name
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Last Name
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Email
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Telephone
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Address1
Address2
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City
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State
select
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Zip
  
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Cell Phone
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Office Address
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Office City
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Office State
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Office Zip
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Office Phone
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Office Email
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Office Fax Number
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Office Contact Person
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Office Contact Phone
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Office Contact Email
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Date of Birth
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Please specify your degree:
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Provider License #
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National Practitioner Identification (NPI) number:
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Are you board-certified in any specialty?
If yes, please specify:
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Are you with a medical group?
If yes, please specify:
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Are you with a university?
If yes, please specify:
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Please list your current primary facility:
Name, City, State
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Type of privileges you are requesting:

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.
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Your specialty/specialties:
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Cross Covering Physician Name:
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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Cross Covering Physician Phone Number:
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Cross Covering Physician Email Address:
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Why would you like to become a member of Touro's medical staff?
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.
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Enter e-mail address to receive application.
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Touro Infirmary, 1401 Foucher Street, New Orleans, Louisiana 70115
Phone: 504-897-7011 Pencil
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