LLU Street Medicine Licensed Care Provider Application Form
Thank you for completing this online application form. If you have any questions while completing this form, please contact Pedro Orta, our LCP Liaison, at 352-875-6376 or porta@llu.edu.
Name
Your answer
Title
(e.g. attending MD, resident MD, NP, PA)
Your answer
Board Certification(s)
(e.g. Family Medicine, Internal Medicine, Preventative Medicine, etc.)
Your answer
Professional Licensing Number
Your answer
Email
Your answer
Work Phone Number
Your answer
Cell Phone Number
Your answer
Are you covered by the Risk Management liability/malpractice insurance at Loma Linda University Health?
Site of current employment
Organization name, title, address
Your answer
Other site(s) of current employment (if applicable)
Organization name(s), title(s), address(es)
Your answer
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