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Medical Staff Pre-application Request
Fountain Valley Regional Hospital and Medical Center

Thank you for your inquiry indicating your interest in applying for medical staff appointment and clinical privileges at Fountain Valley Regional Hospital and Medical Center.  Effective October 1, 2014 there is a non-refundable Pre-application fee of $150.00.  Please submit this fee in the form of a check, made payable to the Medical Staff of FVRH, in order for your Pre-application to be processed.

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

  1. A current, unrestricted license to practice in California and no record of revocation, suspension or probation (of licensure in any state) which became final within past ten years except for administrative reasons not related to crimes or professional competence or conduct.*
  2. Current, unrestricted federal DEA registration.
  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. Current, valid professional liability insurance coverage with a qualified carrier in the following form and amounts: 1 million/per occurrence, 3 million/aggregate, which covers all clinical privileges that you may request.
  5. No record of conviction of Medicare, Medicaid, or insurance fraud and abuse, payment of civil money penalties for same, or exclusion or other adverse actions taken from such programs (i.e., OIG, GSA). [No time limit]
  6. No felony conviction for or withhold of felony adjudication for a crime against a person (includes a no contest plea). [No time limit]
  7. Any felony conviction within the past ten years.*
  8. No record of conviction of, withhold of adjudication for, or plea of guilty or no contest to, any other felony, or any 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, or furnishing of DEA scheduled drugs (Schedules I through V) within the past ten years*.
  9. No record of denial, revocation, termination, or involuntary relinquishment  of appointment or clinical privileges in same or similar specialty at  this or any other hospital or healthcare facility within the past ten years.*

*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: Anesthesia and Radiology.

Please complete the Request Application form at the bottom of this page in its entirety and return it to the Medical Staff Office with copies of all required supporting documentation within 30 days. You will also be required to complete a background check authorization.

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 Fountain Valley Regional Hospital.  If we can be of any further assistance, please contact me at 714-966-8015.

Sincerely,
Susan Potts, CPMSM
Director, Medical Staff Services

Download Pre-Application Form