Initial Authorization to Work

Please complete the application and supporting documents provided below (Step 1 and Step 2) for authorization to work with your
physician employer at St. Dominic Hospital. These documents must be completed and submitted to the Medical Staff Office at the
time of your screening appointment.                    

If you have not already been scheduled for your screening appointment please call Medical Staff Services at 601-200-6846 to
schedule your appointment as soon as possible. Be sure to bring a government issued photo ID to your appointment.

PLEASE NOTE: You may not practice and/or function at St. Dominic's until you have received a hospital issued badge. This
process may take up to four (4) weeks to complete. Please plan accordingly. A valid e-mail address is required for this process
as all communication will be via email.

 

Step 1 - Please print and complete each of the below documents

 

CA - Adjunct Orientation CA - Adjunct Orientation (15530 KB)

CA - Application (Initial Authorization to Work) CA - Application (Initial Authorization to Work) (119 KB)

CA - Code of Conduct Acknowledgement CA - Code of Conduct Acknowledgement (35 KB)

CA - Sponsoring Physician Statement CA - Sponsoring Physician Statement (14 KB)

Step 2 - Please print and complete an applicable job description

 (not applicable for vendors/contract staff - all vendors/contract staff must supply a copy of job description from employer) 
 

CA - Assistant (Non-Patient Care) CA - Assistant (Non-Patient Care) (32 KB)

CA - Dental Assistant CA - Dental Assistant (32 KB)

CA - LPN CA - LPN (33 KB)

CA - LPN (Surgical Assistant) CA - LPN (Surgical Assistant) (33 KB)

CA - RN CA - RN (33 KB)

CA - RN (Surgical Assistant) CA - RN (Surgical Assistant) (34 KB)

CA - Surgical Assistant CA - Surgical Assistant (34 KB)

Additional Resources

 

CA - Code of Conduct CA - Code of Conduct (271 KB)

CA - Flow Sheet (Initial Authorization to Work) CA - Flow Sheet (Initial Authorization to Work) (87 KB)

CA - Request for Additional Practice Locations CA - Request for Additional Practice Locations (56 KB)

 

 If you are a currently authorized clinical assistant needing to complete the renewal process click HERE.