9 October 2017

c/o Medical Staff Office – Box 1639

Re: First Last,

Dear ,

We wish to request Medical Staff appointment for First Last, Title in PRIMARY SPECIALTY effective MM/DD/YYYY.

First Last, Title’s role at UCSF will be JOB TITLE within the DEPARTMENT/DIVISION. clinical duties will include DETAILS OF CLINICAL DUTIES, and will be proctored by PROCTOR NAME.

ANY RELEVANT EDUCATIONAL HISTORY, LICENSURE INFORMATION, FLAGS IDENTIFIED, BILLING DETAILS, AND/OR RELEVANT INFORMATION.

First Last, Title is and BOARD SPECIALTY/PLAN.

will begin clinical activities at PRIMARY LOCATION, and malpractice coverage will be provided by MALPRACTICE CARRIER NAME.

After reviewing the enclosed application, I recommend that First Last, Title is clinically competent to perform the requested privileges and to the best of my knowledge, there are no health issues that might impact his/her ability to perform the requested privileges.

If you have any questions regarding this application, please call DEPARTMENT CONTACT NAME at (***) ***-****

Sincerely,

A

B

C

A

B

C