.0 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as. Clinical Privileges Update Form

Size: px
Start display at page:

Download ".0 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as. Clinical Privileges Update Form"

Transcription

1

2

3 Clinical Privileges Update Form ~, John Mason Department of Otolaryngology. U~-rr"tRSITY C!/ \lirgil\.;y\. HEALTH SYsTEM I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed: * ->. '--."". --., *Privileges not renewed are not reported as being voluntarily relinquisbed unless tbis is donewbile you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filedwitb the National Practitioner Databank DATE I / - As the Division Head/QI Liaison and Dep tment Chair.edical Director, we have reviewed the abovenamed clinician's level of experience, past p rmance d quality indicators (if renewing privileges) as related to requested privileges and agree that the a ove named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We r~~as follows:..0 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as ~~.. D D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the cllnical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted but restricted as foijows: _ DATE DATE Revised 3/1/2006

4 Clinkal Privileges Update Form Mason Department of Otolaryngology UNI\.l.'E :;:RSIT'Y.7' qt\!lrc~inia HF..ALTH SYsTEM I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): / 7 Current Privileges not to be Renewed:* 7 / w,,," ~'".~. V''','.,.,..-" '. ~-.~'.' ~.w" AV',. ','~'_._-_~' ~ _v,w., _v.. ~'v_,..,... ~~,_''' «_~~,,~,, ~.,~~.~,.~.~.v_. ""'_"_",,"_.-...,.~ ~_-'_'V-.w.-. -_" v=~'''_~","", _ ~_=v 'M."_"_V-.h"_ Y, '" 'h" "".'~'._,~ ~ *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. As the Division Head/QI Liaison and Depa ment Chair edical Director, we have reviewed the abovenamed clinician's level of experience, past pe ormance d quality indicators (if renewing privileges) as related to requested privileges and agree that the ve named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We f~~ follows: M Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. o Should have clinical privileges granted but restricted as follows: _ 41'"kr~ DA Revised 3/J

5 Request for Laser Privileges University of Virginia Health System I Dei:artment of Ph sician Name: Division of : Please check those types of lasers that you are requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: Completed Formal Training Limited Experience - without formal training Extensive Experience - without formal training PRIVILEGES Laser Privileges Requested Type of Experience Laser Surgery - Argon /' Laser Surgery - CO2./ \ Laser Surgery - Holmium Laser Surgery - KTP Laser Surgery - Pulsed C Laser Surgery - Yag Laser Surgery - Lite Sheer / Dlte Clinician's Signature As Division Head/QI Liaison an Department hair, we have reviewed the above-named clinician's level of experience an st erfo ance as related to requested privileges and agree that the clinician's qualifications are appropriate. r!date _--..:.lt~'['1-'---_ Date Department hair Please return completed form to Clinical Staff Office, Box Rev 7/2003

6 ,~' ~ O_,~ Name Medical REQUEST FOR CLINICAL PRIVILEGES Department of Otolaryngology University of Virginia Health' Sciences Center School and Year of Graduation c_u_ ~ ~_~ ~~~~~/~~+I _ UN{U~?t cf VI~t-Il+ Flesidency Training Location and Years Fellowship!Post-Residency Training Location and Years B,oard Certification in /'9 9 z- 19<tz - /j91 l<=t ;-~ ~.::uj>.. ty'~ ro~ Year of Certification / Admitting Privileges? ErYes 0 No Virginia Ambulatory Surgery Center Privileges? ~ DNo PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. l l_m_~_d~_c_~l? According to category, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake patient management except in emergency. Category B The applicant will occasionally manage patients or assist in management., Consultation will be sought in the event of anticipated or actual difficulties. Category C The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. Type 1 Type 2 According to type, enter 7, 2, or 3 in the EXPERIENCE column. Completed Formal Training Program Limited Experience- without formal training Type 3 Extensive Experience - without formal training PRIVilEGES REQUESTED AREAS - CATEGORY TYPE REOUESTED EXPERIENCE, (A. Bore) (1,2or3J. DISEASE Consultation c. 1 E~;i~; ti~; ~ ~d-m ~_;; ~g~~ ;~t _ c- i RECONSTRUCTION/ AESTHETICS... _......_ _, _.... Interpretation of tests, ' v \ Consultation "" I...- K _. Evaluation and Management \f) I

7 , '. II. RROCEDURES. -.Page? ' Accordin{J to c8te{jory, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake the procedure except in emergency. Category Category Type 1 Type 2 Type 3 B C The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. Accordin{J to type, enter 1, 2, or 3 in the EXPERIENCE column. Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training ' -, < PRIVilEGES,REOUESTED. AREAS - CATEGORY. TYPE' < -, REQUESTED EXPERIENCE".'..,(A, B or C) (1,2 or 3) LIPS I NECK..~~~~.Es!~!!2.~!..f..~~.p. _.._.._. _S _..._. _ _ _. _.._ _..._._. _ Excision (Subtotal) and reconstruction with local or distant flaps C- \ -_ _ _ ae_ _._ _ _._ _._ Lip..._ shave _._-_.._..._..-.._._---_.... _-_.. _---_... -_...._ _ C -. \._- _. Vermilionectomy _. u C _ _._... \ Wedge resection c- \.!'_'!:~~.~.~~~.~.~~.~.E!..?::.~~.~.! _. 8::...1::. Arytenoid Adduction Creation TE fistula for speech \...~!!:!.i!.~.!!!.~..~~«?~ _.. _ ~.... _....~~~;~:i~~~;~~.. E:~~~~ i~.!ryten?id:5~~.y_... _. G _\ ~!!~ ~ ~~~.. ~! ~~::.~!~ ~.. Cong;;~it~i.. 't _ \~-...cysts c: ,---- ::::::::=~:s ~=:::::~ Bronchiogenic cysts :::~==:~~~~:~~:~: Oermoids C..- \..._ _....._.... _._. Lymphangiomas C \ 1- _ _... - _ Teratomas _ C _ \....!.~~~p.!.?.~~~..i..:.y~.~.~...c:.1._.._. :=:=::~~::~.:=:::: ~:~::::::=::~~:~~~ ~~~~~~h.y:~~~:~!~i.!.. i.:=:~::~:=~:==~:::~=:::~~:::=:=::::=:::~::~:::~:~~ :::=::~=:~~!~:::::~~:: Cricropharyngeal myotomy G'._~.xc!~!?-;;~~~~~~~~~~~~~=:=:~==::~~=~~~:~~... ~..~~==~:=:~ ::~~===(::::::. Diverticulectomy C--r \ =....5.~..!.~.~~~~?.~_~~.~..~.:~..~:!~~~.~! I~_ry~~:~L.!~.~:~~.~~.~ _ L. ~~;.~;;:.~-;~;~~~~~~=-.::::= Exploration and reduction of laryngeal nerves 6 =±= \ Gelpaste injection ~ \.._ - - _ R:..... L "...~:~!.~~.:.t..~.~.~.:!~~.y. ~... J.. _ _ n _ _ 1&0 neck abscess C- I n. _ _._ _ _ vessel grafting.. Major..;;-e ss e I" iigatlon _ " _._ _ _. c::;... a-.. _ t..- T....

8 NECK - cont'd Modified neck dissection C.- \ NOSE AND MAXILLA :~Ne~.~!?..~al~~~~~X?.~:Y=~~:~~:~~~=-~"=~=::~~~~::~~ ~..~~..~~:~=::~::: :=~~:~::=~= -~~;~~~;~~id~~~~~'~~""'--"--'-'-"""'-"'---"-"'" ~ - - \. Ph ~;y;;g~-;i ~y-oto;;,y e , _- Ph I, ~ _ ~~~gea..e..~~.~~:!~~~ _._.._... ~g ~._....~~.~.~~.~! ~~c~.~.~~~~?.~._. ~. ~..~_~al~~..nod~_~j.?.~..~.._._. ~..~ _. Subtotal laryngectomy Supr~glotticlaryngectomy ~=::=:B'..~::~~..:::~~:=:::i~::~:~: _.. _!.~y~~~~~.y. (la'r~~.~!~s!~~~.~.. ~ L _...!..!:.~~~.~~~l.e..:~.~.~.~_._. _.. ~.._ L_. Thyroidectomy Tot~l i ~;y;;g~cto;;:;y c, C.. -..t \ With dissection C - --l _ " -,. _:~~~p.~~.!~...!!..y..~!.~:~y.!. _.._.._. _ ~.t. Tracheal resection with repair..t;:ach~otomy _ ~ C.. I\.

9 OTOLOGIC..~2~_~9.!2~~.!~.~Y_ _ 0.: _.. Composite resection - primary and tumor with RND, Le., Primary in floor of mouth, alveoli, tongue, G \ buccal region, tonsil or any combination _._ _._. _._ _ _ _ _ _ _ _ _._ _ _ _ u _.... _ _ Excision of ranula "_".._.s:...._t. Combined. (.._" _ " \. Simple C. \ '-Partialglossectomy C , -.-. ~~~i~~~~t~~~:~:~~!~~y::~~:=~~=~~~~~=::~:== :=::::~~::~~~:::::::::: ~:::~::::::::~~~::~::: =f~~:~-_~l~~~~~~y- ==~~:=~==_-=--==:::~~~:~=:~:::~=~ :=~::~:f;~:~~:=~::::: ~::::::=:~::~::::~ T&A C \...~.~.~.~y.!!.!~~~.!~~._~~~ ~p..:~~.~~~~~....~~_:!~!?_~:~~~.~~_?_~.~."~:~.~.~~.~_~.:.:~~.~.~.." (. _ L... " "..._..."_..C-_.._.... :J.._._._._...~~~~~~..~~.~:..~.~.~~.~.~.~:~~.!~~..."_..._. ~ 1...._ Facial nerve graft or repair including VII to other cranial nerve C _ _ _... u _ _. ~.~~.~~~~.~~~.~._. " _._.._._. _.._.._.._.._,...L._~~y.~~~~~_~.:.!.~.':!:'.Y.. (;... _ ~..._.....~?.~~~~~..~~~.~~.~~ ~~~?!.~.~:.~!!.1)'......_..., _ ~ _._1....~y!.~~y_~?!.~~~ _. _.._... <;;:.... L _....~y.~~~y_~~~~.y...!~~..!~~~.._._._._. _ ~- _ -' _.....~.~~.~:.~.~~~~~.~._."_ "._.. _ ~ _ 1_. _~.~~~~~..!~~~~~~.~.~~.~..!:.:.~.~:.tio~......_ 0. _..._ L _.._~.~.?.!:.~! ~~~~~~~:~.!~.~y...._..f.:' ~~.?i.~!!..~~~.~:~~._~~~:._~~~~.~~!.?..~. _....._. ~_.. _ ~.~.~?_~~:~~.~~!.?~.~_:~~~~~~..~.~.~.~~.ry..~~~~.~ G _ L. _.~.:p..~~!...~~~.~.~~~.~~.!::'.i.~.~.~.~.!.~~.~.~.~~._.... ~.._.L. Resection acoustic neuroma _ C:-: - L. Middle cranial fossa.. 5::: _._ _......_._.!.~~~~~.~~Y.~~~~~.~:...~.~.~.~~~.!!.'!"~.toi~L _.. ~ _.~. Resection glomus tumor.5= L _-. Infratemporal fossa _ k "..\. Transcanal _C:::... _ _.J _..!.~~~.~.~.~.~!~~~. _..._ ~.... L......~~.:.:~!.~!.?~.y. " _ G.:-.... l......~.~~.p..i.: ~.~.~.!.?!~~_~~~.!!.'.Y.. ~ ~!~.p..~.~:.:.~~.~y _ "..c-. _... J ~!~.p..:~.~_?~!!.~~.~~~~.~ _ - _!::::_...!-...!y.~~~.~~:..~.~.~:.::.~.~.~y. " " ~ - t..!y..~~~.~.~.~~~.~~.._.._.._. -.-~ ~. Tympanoplasty with mastoidectomy V

10 PLASTIC AND RECONSTRUCTIVE Blepharoplasty, _a_ _... u _.._...r..~.. _~~~.~~~~sia r!pai~. _~!!.~~..!!Pai.~. _...._.. _~...._1_. Cleft palette repair C, I =~~~d~;~t~~-y":=--=~=~~-=-===::~~~==-~-~= =:=:=:~~-.:::~:~:: :~~~=~~~::=...~!..~~~!:l_skin I.!~~?n~_.._.._. _ ~._ L._.._..!I~~.!:~.~edures._... ~ _. 1_._._ ~'!.:~~ Grafts c...!. _. Split thickness skin.. ~._...._...1 _.._. Full thickness skin.~.1.. _. Composite....c _ Dermal._._.~.._._ 1_..._ Buccal _.~...1.._... Other (specify), =f.~..p.ia ~~..~=~===::~~.~:~_~=~.~=~=:~=~~=:==:=~::~:~:=::: ~:~~=~=e;.::~=:~:~ ~:~~==~[~~:: =~~~:.~i~~~~_...~::==:::~~:~~:~===~~~~:==~~===:~: :==::~!-._~:: ::::~=~~~::=:.. Oroantral fistula repair c... \ :::~!~pta~~~=~~~=~=::::=~~:~:==~:~~::~==-~:~:~==::~..~=:~= :~~~:::::=~::~~~=:: ~:~:=~:~:i:~~~ _..C.._.. - i Neck ""-"'-'c:.---' --_.., _.._. Shoulder /Neck _- 'A - _.L.._. Forehead/Scalp....~.. L.. Pedical flap procedures Chest Cheek _ ~....L.....~~!!.~~.~.... _.._..._._.. _.._..~-..- _.. 1. Prognathism correction. It "Z:..- _. - _ ~ r. :.. _.... _. _~~.~?!'s~~~~~~_!~~~.~.~~!.~. _ ~ _. Reduction facial fractures C._._.._ L. Frontal C..._... _L _ Malar h :: _. Malar with orbital floor.. ~ _ Mandibular Closed _C \ O~ C Maxilla '=: _._ -L Le Fort I _ c..1._._. Le Fort II Le Fort III... c. _ ~.

11 PLASTIC AND RECONSTRUCTIVE - cont'd Nasal Orbital blowout.._ _..._..-_.. Other fractures (specify), =_ ~:~~:~ roi.~~~~}~~~~~i.~~~~~~:~~=~::::::~:=::~~~::~~:::~::::::~ :::~~~::~~:::=::::::=:: ::::::::~:~:::::~::...Rh~!:l~pla~.!Y_.._..._....._..-.- ~11:- -- _.:.t......~.~~?~.~!~~y y \. ::~~=:~~~c::::=~ Scar revision c.,. \ -S~~-~p.X~_~!Y.~:=~~=~:==~:=~~:==~:::::: :===::::~:: :~=~-~::::~\:::~~: _~~~...!I~p~~~.~o_~._.._.... _ f.:i: _ _. Tracheoplasty U \ SALIVARY GLANDS Marsupializing Wharton duct with or without stone removal _. _ _ n.... _ _ _..... _ _. _ u _ _ _ ~_ _ Parotidectomy (Radical) C. \ With nerve graft C C Without nerve graft - C; - --,. ::!~~~a~~!~~]:ai ~i~~~::~~~f.~~~:~~~::::=~~:::..~:~~ ~~~~~~:(:"~=::~:~ :~:::=:..-\~~:=~=:: Superfici~1 parotidectomy with nerve dissection and c- preservation Totai -p;;:otkjecto ~y-~ith f-aciaine~~~ p ~e~-;; ~ati;;-~"-"" Z; - -- "\ OTHER Bronchoscopy - Diagnostic ~ _. ~.._._. With foreign body removal C \ With structure dilatation -- -C -.-_ i: _......_..... _-- _.-- _-_...- _..-_ --. _ _ _~~!:l_~~~~.~.~~.~~~.!~.~~._._... _.. ~;.. _.1. _._.. Esophagoscopy - Diagnostic _._ ~ 1... _. With foreign body removal C. \ With structure dilatation.-- -c:,; \ - -j.: ES S _--.-_ _ f _... _.._ _ _ _ -....~~~~.~.~.~?_~E.y... _ ~... _ ~....~~~.~!._~~.~~.~!2:..~.!~~5:!!!.~..~~.?~~~~~.~.~~.~..~:~L~.!:'.~...._ f2. _.... _.._J.. ~~~i.~~~~ii~~~~9.p.y~::~~:~:~~:::::::::::=~~:::~~:~~:::::=:::~:==~:~~:::::::~=: =:~:~::~.~~::::=:: ::::~::::~::L.~::~:: Nasopharyngoscopy '''0:'' \ :::~~~~~~~~~p.y.:~::~::::~=:::::~::=::~~~:=:=~::::::::=:::~~::=~~::~==:~_~::=:~ ~::~=~~:::::&.::=::~~: ~::::~:=::::I:~:~:~:= Laser surgery of tracheal lesions ~ 'l- 7 7 DATE /_ As Division Head/QI Liaison and Department ave reviewed the above-named clinician's level of experience, past performance and qu in tors (if renewing privileges) as related to requested privileges and agree that clinician's qualifications are appropriate. The following indicators have been reviewed for reappointment.

12 I..... Since the date of the last appointment, we have reviewed applicable information from the following sources of quality data: o Physician's Health & Mental Status o Inpatient Attending Performance o Morbidity and Mortality Reports o Blood Usage Reports Drug Usage Reports o lntection Reports Invasive/Non-Invasive Procedures o Medicall Records Documentation o Patient/Family Satisfaction o Sentinel Events/Risk Management Reports Consultation Attending Performance o Outpatient Clinical Practice o Peer Review of Clinical Performance o Other: We find as follows: o Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in _ months. I I DATE clin _pri:oto A:04/11/97

Loma Linda University Medical Center Loma Linda, CA HEAD AND NECK SURGERY PRIVILEGE FORM

Loma Linda University Medical Center Loma Linda, CA HEAD AND NECK SURGERY PRIVILEGE FORM Name: Page 1 of 6 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All

More information

Clinical Privileges Update Form Kenneth Liu Department of. Radiology I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,

More information

SUTTER MEDICAL CENTER, SACRAMENTO Department of Surgery Otolaryngology/Head and Neck Surgery Section - Delineation of Privileges

SUTTER MEDICAL CENTER, SACRAMENTO Department of Surgery Otolaryngology/Head and Neck Surgery Section - Delineation of Privileges INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown or Capitol Pavilion Surgery

More information

~ ~..._..._...~..._ CLINICIAN SIGNATURE

~ ~..._..._...~..._ CLINICIAN SIGNATURE Clinical Privileges Update Form UNlVEHSrry qrvirginiau Barbara Wilson Department of Dermatology L--. HEALTH SYsTEM ~ ~ I have reviewed the privileges previously granted to me and request the following

More information

., Clinical Privileges Update Form Susan Modesitt Department of Obstetrics and I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,

More information

Otolaryngology-Head and Neck Surgery Clinical Privileges

Otolaryngology-Head and Neck Surgery Clinical Privileges Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,

More information

Clinical Privileges Update Form

Clinical Privileges Update Form Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,

More information

SCOPE OF PRACTICE PGY 1-6

SCOPE OF PRACTICE PGY 1-6 PGY1 Complete history and physical on each patient admitted as assigned by the attending surgeon. Participate in daily ward rounds. Assist operating surgeons and senior residents in the operating room

More information

UNMH Plastic Surgery Clinical Privileges

UNMH Plastic Surgery Clinical Privileges All new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 12/19/2014 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.

More information

UNM SRMC PLASTIC SURGERY CLINICAL PRIVILEGES.

UNM SRMC PLASTIC SURGERY CLINICAL PRIVILEGES. o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved

More information

Monitoring of the accomplishment of the stated objectives will be performed using the following methods:

Monitoring of the accomplishment of the stated objectives will be performed using the following methods: July 2011 ROTATION: PLASTIC SURGERY ROTATION DIRECTOR: Tim Miller, M.D. SITES: RRUMC; Greater Los Angeles VA Medical Center, Olive View UCLA Medical Center GOALS AND OBJECTIVES: 1. Obtain clinical experience

More information

FAMILY MEDICINE CLINICAL PRIVILEGES

FAMILY MEDICINE CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 4/3/2013. Applicant: Check off the Requested box for

More information

Privilege Request Form Orthopedic Surgery

Privilege Request Form Orthopedic Surgery Privilege Request Form SECTION I GENERAL REQUIRERMENTS ORTHOPEDIC SURGERY Requested STAFF CATEGORY Active Courtesy Consulting Affiliate INITIAL APPOINTMENT Basic Education; MD or DO Minimum Formal Training

More information

Regions Hospital Delineation of Privileges Family Medicine

Regions Hospital Delineation of Privileges Family Medicine Regions Hospital Delineation of Privileges Family Medicine Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and

More information

DEPARTMENT OF SURGERY OTOLARYNGOLOGY-HEAD AND NECK SURGERY CLINICAL PRIVILEGES REQUEST FORM

DEPARTMENT OF SURGERY OTOLARYNGOLOGY-HEAD AND NECK SURGERY CLINICAL PRIVILEGES REQUEST FORM DEPARTMENT OF SURGERY OTOLARYNGOLOGY-HEAD AND NECK SURGERY CLINICAL PRIVILEGES REQUEST FORM Appointee: Date: NOTE: This request should be returned to: Medical Staff Affairs Office, Hershey Medical Center,

More information

PLASTIC SURGERY CLINICAL PRIVILEGES

PLASTIC SURGERY CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 11/04/2015 Applicant: Check off the Requested box for

More information

UNMH Family Medicine Clinical Privileges

UNMH Family Medicine Clinical Privileges All new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 07/31/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.

More information

PLASTIC AND HAND SURGERY CORE OBJECTIVES

PLASTIC AND HAND SURGERY CORE OBJECTIVES PLASTIC AND HAND SURGERY CORE OBJECTIVES Through rotation on the plastic and hand surgery service, residents shall attain the following goals: I. Patient Care A. Preoperative Care: Residents will evaluate

More information

DERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS

DERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS DERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS 2017 DERMATOLOGY CLINICAL SERVICE RULES AND REGULATIONS TABLE OF CONTENTS I. DERMATOLOGY CLINICAL SERVICE ORGANIZATION... 3 A. SCOPE OF SERVICE... 3 B.

More information

UNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To

UNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective April 28, 2017: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)

More information

Pediatric Otolaryngology Rotation (Ped Oto)

Pediatric Otolaryngology Rotation (Ped Oto) Pediatric Otolaryngology Rotation (Ped Oto) This rotation provides a comprehensive, mentored exposure to the care of patients in pediatric head and neck surgery, rhinology and sinus surgery, otology/neurotology,

More information

GENETICS CLINICAL PRIVILEGES

GENETICS CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for

More information

PRIVILEGE APPLICATION FORM - [Mercy Medical Center]

PRIVILEGE APPLICATION FORM - [Mercy Medical Center] Current Privilege Status Key Practitioner's Current Privilege status is signified in ( ) preceding each privilege. G = W = Withdrawn T = Temporary P = With Proctor A = Assist with C = With Consult E =

More information

Otolaryngology Residency Program Overview

Otolaryngology Residency Program Overview Otolaryngology Residency Program Overview The Otolaryngology Residency Program at Penn State Health Milton S. Hershey Medical Center resides within a university-based medical school atmosphere and academic

More information

General Surgery Clinical Privileges

General Surgery Clinical Privileges Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,

More information

fll School Teaching. Discfiversng. Caring.-

fll School Teaching. Discfiversng. Caring.- DEPARTMENT OF OTOLARYNGOLOGY - HEAD & NfiCK SURGERY lfs**+ EVMS HEARING & BALANCE CENTER WWW.EVMS.EDU M %/ m/l ^^ 600 Gresftam Drive. Suite 1100 Noifolfc. VA 23507-1904! Pfton* 757 388.G200 Fa»: 757 388.6201

More information

UNM SRMC SURGICAL ONCOLOGY CLINICAL PRIVILEGES.

UNM SRMC SURGICAL ONCOLOGY CLINICAL PRIVILEGES. o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved

More information

Loma Linda University Medical Center Loma Linda, CA 92354

Loma Linda University Medical Center Loma Linda, CA 92354 Name: Page 1 of 7 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All

More information

SURGICAL ONCOLOGY MCVH

SURGICAL ONCOLOGY MCVH SURGICAL ONCOLOGY MCVH PGY-4 and PGY-5 Medical Knowledge: Demonstrates knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences;

More information

Rotation Specific Learning Objectives CCFP-EM Residency Program. Plastic Surgery

Rotation Specific Learning Objectives CCFP-EM Residency Program. Plastic Surgery Rotation Specific Learning Objectives CCFP-EM Residency Program Plastic Surgery of the Rotation To utilize the relevant competencies contained within the CanMEDS-FM roles to effectively evaluate, diagnose

More information

UNM SRMC GENERAL SURGERY CLINICAL PRIVILEGES.

UNM SRMC GENERAL SURGERY CLINICAL PRIVILEGES. o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved

More information

Plastic and Reconstructive Surgery

Plastic and Reconstructive Surgery Plastic and Reconstructive Surgery General Description Office for Clinical Affairs (515) 271-1629 FAX (515) 271-1727 Elective Rotation This elective rotation in Plastic and Reconstructive Surgery (PRS)

More information

Excision of Submandibular Gland

Excision of Submandibular Gland Patient information Excision of Submandibular Gland Ear, Nose and Throat Directorate PIF 863 V5 Your consultant has advised that you have excision of submandibular gland. What is excision of submandibular

More information

SPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges

SPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges SPECIALTY OF PULMONARY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Internal Medicine by the American Board of Internal Medicine or the American

More information

PULMONARY MEDICINE CLINICAL PRIVILEGES

PULMONARY MEDICINE CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for

More information

Clinical Privileges Profile General Surgery. Kettering Medical Center System

Clinical Privileges Profile General Surgery. Kettering Medical Center System Printed Name Clinical Privileges Profile General Surgery Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested.

More information

LEE MEMORIAL HEALTH SYSTEM LEE COUNTY, FLORIDA

LEE MEMORIAL HEALTH SYSTEM LEE COUNTY, FLORIDA LEE MEMORIAL HEALTH SYSTEM LEE COUNTY, FLORIDA CCH, GCMC, HPMC AND LMH DEPARTMENT OF SURGERY Rules & Regulations Section 1 - Purpose of the Department: The purpose of the Department of Surgery is to develop,

More information

Goals and Objectives revised 9/09 OTO4 Facial Plastics and Reconstructive Surgery Rotation, Johns Hopkins University

Goals and Objectives revised 9/09 OTO4 Facial Plastics and Reconstructive Surgery Rotation, Johns Hopkins University PGY-4 GBMC/JHH Facial Plastics and Reconstructive Surgery Rotation. Each OTO4 spends 3 months on the combined GBMC/JHH FPRS service (OTO4 FPRS resident). This rotation ensures that the resident has time

More information

CRITERIA FOR GRANTING MEDICAL PRIVILEGES

CRITERIA FOR GRANTING MEDICAL PRIVILEGES CRITERIA FOR GRANTING MEDICAL PRIVILEGES Please review these categories carefully to determine those privileges for which you are qualified. Indicate your request below by checking the appropriate category.

More information

National Fee Analyzer. Charge data for evaluating fees nationally

National Fee Analyzer. Charge data for evaluating fees nationally National Fee Analyzer Charge data for evaluating fees nationally 2013 Contents Introduction...1 Key to Proper Reimbursement... 1 The Medical Coding System... 1 What This Book Has to Offer... 2 A Coding

More information

Policy for Procedures of Limited Clinical Benefit (including low priority treatments)

Policy for Procedures of Limited Clinical Benefit (including low priority treatments) APPENDIX 1 Policy for Procedures of Limited Clinical Benefit (including low priority treatments) Please read in conjunction with the Policy for Individual Funding for Treatments outside Commissioned Services

More information

CERTIFICATION EXAMINATION IN OTORHINOLARYNGOLOGY AND HEAD-NECK NURSING

CERTIFICATION EXAMINATION IN OTORHINOLARYNGOLOGY AND HEAD-NECK NURSING CERTIFICATION EXAMINATION IN OTORHINOLARYNGOLOGY AND HEAD-NECK NURSING HANDBOOK FOR CANDIDATES Application Deadline April 16, 2018 Application Deadline September 17, 2018 EXAMINATION DATES SPRING 2018

More information

INTERNAL MEDICINE CLINICAL PRIVILEGES

INTERNAL MEDICINE CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 11/20/2015 Applicant: Check off the Requested box for

More information

Loma Linda University Medical Center GENERAL SURGERY Privilege Request Form

Loma Linda University Medical Center GENERAL SURGERY Privilege Request Form Name: Page 1 of 9 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All

More information

Pediatric Cardiothoracic Surgery Clinical Privileges

Pediatric Cardiothoracic Surgery Clinical Privileges Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,

More information

MEDICAL STAFF BYLAWS MCLAREN GREATER LANSING HOSPITAL

MEDICAL STAFF BYLAWS MCLAREN GREATER LANSING HOSPITAL MEDICAL STAFF BYLAWS MCLAREN GREATER LANSING HOSPITAL Final Document May 16, 2016 Horty, Springer & Mattern, P.C. 245957.7 MEDICAL STAFF BYLAWS TABLE OF CONTENTS PAGE 1. GENERAL...1 1.A. PREAMBLE...1 1.B.

More information

OTOLARYNGOLOGY IV: RESIDENCY BENCHMARK EDUCATIONAL GOALS AND OBJECTIVES LARYNGOLOGY AND CARE OF THE PROFESSIONAL VOICE- PGY4 Resident

OTOLARYNGOLOGY IV: RESIDENCY BENCHMARK EDUCATIONAL GOALS AND OBJECTIVES LARYNGOLOGY AND CARE OF THE PROFESSIONAL VOICE- PGY4 Resident OTOLARYNGOLOGY IV: RESIDENCY BENCHMARK EDUCATIONAL GOALS AND OBJECTIVES LARYNGOLOGY AND CARE OF THE PROFESSIONAL VOICE- PGY4 Resident I. Medical Knowledge 1. Laryngeal physiology and anatomy 2. Specialized

More information

Handbook for Fellows and Residents in Head and Neck Oncologic Surgery

Handbook for Fellows and Residents in Head and Neck Oncologic Surgery Handbook for Fellows and Residents in Head and Neck Oncologic Surgery Center for Ears, Nose Throat & Allergy, P.C. Issued to: Date: 1 Handbook for Fellows and Residents in Head and Neck Surgery A. Introduction

More information

NEPHROLOGY CLINICAL PRIVILEGES

NEPHROLOGY CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 02/15/2017 Applicant: Check off the Requested box for

More information

Plastic and Reconstructive Surgery Resident Profile Kevin Zuo

Plastic and Reconstructive Surgery Resident Profile Kevin Zuo Plastic and Reconstructive Surgery Resident Profile Kevin Zuo September 2016 About me My name is Kevin Zuo. I m a PGY 2 resident in plastic and reconstructive surgery at University of Toronto. I was born

More information

Post-Op hemorrhage repair. Is it billable?

Post-Op hemorrhage repair. Is it billable? Post-Op hemorrhage repair. Is it billable? August 10, 2017 Can I bill for taking the patient back to the OR to explore and repair post-op hemorrhage on day post-op? I heard that all complications are included

More information

OPTIONAL MID-YEAR EVALUATION FORM FOR MICROGRAPHIC SURGERY AND DERMATOLOGIC ONCOLOGY FELLOWSHIP TRAINING

OPTIONAL MID-YEAR EVALUATION FORM FOR MICROGRAPHIC SURGERY AND DERMATOLOGIC ONCOLOGY FELLOWSHIP TRAINING OPTIONAL MID-YEAR EVALUATION FORM FOR MICROGRAPHIC SURGERY AND DERMATOLOGIC ONCOLOGY FELLOWSHIP TRAINING 1. FELLOW'S NAME 2. TRAINING INSTITUTION 3. FELLOWSHIP PROGRAM DIRECTOR 4. REPORT IS FOR PERIOD

More information

Privileges for: General Surgery

Privileges for: General Surgery Document Review: MEC 8/27/09, 2/27/2014, 1.23.2015, 4.28.2016; Board: 9/14/09, 6/29/10, 5/5/2014, 3.2.2015, 5.2.2016 ST. ELIZABETH - EDGEWOOD ST. ELIZABETH - FLORENCE ST. ELIZABETH - FT. THOMAS ST. ELIZABETH

More information

Privileges for San Francisco General Hospital # 10

Privileges for San Francisco General Hospital # 10 PEDIATRICS 2014 FOR ALL PRIVILEGES: All complication rates, including transfusions, deaths, unusual occurrence reports, patient complaints, and sentinel events, as well as Department quality indicators,

More information

X X AHP Clinical Privileges Update Form Joseph Fallon, PA Department of Radiology -------I have reviewed the privileges previously granted (COP)' attached) to me and request the following

More information

APP PRIVILEGES IN MEDICINE

APP PRIVILEGES IN MEDICINE APP PRIVILEGES IN MEDICINE Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA, NP or CNS program Current Licensure as a PA, RN or CNS in the

More information

MEDICAL STAFF BYLAWS

MEDICAL STAFF BYLAWS MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF THE CHRIST HOSPITAL MEDICAL STAFF BYLAWS Adopted by the Medical Executive Committee: April 24, 2014 Adopted by the Medical Staff: May 13, 2014

More information

LOMA LINDA UNIVERSITY MEDICAL CENTER SURGERY SERVICE RULES AND REGULATIONS

LOMA LINDA UNIVERSITY MEDICAL CENTER SURGERY SERVICE RULES AND REGULATIONS I. ORGANIZATION LOMA LINDA UNIVERSITY MEDICAL CENTER SURGERY SERVICE RULES AND REGULATIONS A. Membership: 1. The Surgery Service shall be made up of Physicians and Dentists who perform surgical procedures

More information

Clinical Privileges Profile Family Medicine. Kettering Medical Center System

Clinical Privileges Profile Family Medicine. Kettering Medical Center System Clinical Privileges Profile Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested. Applicants have the burden

More information

SYNERGY PLASTIC SURGERY

SYNERGY PLASTIC SURGERY Patient s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Race Ethnicity Language Any restrictions for contacting you? No Yes E-mail Age Birthdate SS# Gender

More information

APP PRIVILEGES IN SURGERY

APP PRIVILEGES IN SURGERY APP PRIVILEGES IN SURGERY Education/Training Licensure (Initial and Reappointment) Required Qualifications Successful completion of a PA or NP program Current licensure as a PA or RN in the state of California

More information

NURSE PRACTITIONER (NP) CLINICAL PRIVILEGES ORTHOPEDIC SURGERY

NURSE PRACTITIONER (NP) CLINICAL PRIVILEGES ORTHOPEDIC SURGERY Name: Page 1 Initial Appointment (initial privileges) Reappointment (renewal of privileges) All new applicants must meet the following requirements as approved by the governing body effective: / /. Applicant:

More information

SCOPE OF PRACTICE PGY-1 PGY-5

SCOPE OF PRACTICE PGY-1 PGY-5 The Residency Review Commission on Otolaryngology requires demonstrated progressive responsibility in cognitive and procedural patient management. A concrete list of procedures limiting the progression

More information

ADVANCED SURGERY OF THE HAND CLINICAL PRIVILEGES

ADVANCED SURGERY OF THE HAND CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 09/02/15 Applicant: Check off the Requested box for each

More information

Nurse Practitioner dictionary was approved by PMSEC on September 14, 2017

Nurse Practitioner dictionary was approved by PMSEC on September 14, 2017 Summary Page NURSE PRACTITIONER DICTIONARY APPROVAL Nurse Practitioner dictionary was approved by PMSEC on September 14, 2017 REVIEW PANEL COMPOSITION The panel was composed of two co-chairs with expertise

More information

APPLICATION FOR CLINICAL PRIVILEGES (MEDICAL)

APPLICATION FOR CLINICAL PRIVILEGES (MEDICAL) APPLICATION FOR CLINICAL PRIVILEGES (MEDICAL) Granting, reviewing, and changing of clinical privileges for the staff of FIRST CHOICE COMMUNITY HEALTHCARE (FCCH) will be in accordance with the FCCH policy.

More information

Hospitalist Medicine Clinical Privileges

Hospitalist Medicine Clinical Privileges Name: Effective from / / to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants should meet the following requirements as approved by the governing body,

More information

PEDIATRIC ENDOCRINOLOGY CLINICAL PRIVILEGES

PEDIATRIC ENDOCRINOLOGY CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 04/03/2013. Applicant: Check off the Requested box for

More information

Neurotology. Background. Practice area 407

Neurotology. Background. Practice area 407 Practice area 407 Clinical PRIVILEGE WHITE PAPER Neurotology Background Neurotology is the American Board of Medical Specialties recognized subspecialty of otolaryngology that involves the diagnosis and

More information

UNMH Nurse Practitioner (CNP) and Physician Assistant (PA) Ambulatory Special Non-Core Procedures (Appendix A) Name: Effective Dates: From To

UNMH Nurse Practitioner (CNP) and Physician Assistant (PA) Ambulatory Special Non-Core Procedures (Appendix A) Name: Effective Dates: From To All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective March 31, 2017: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)

More information

DELINEATION OF PRIVILEGES - FAMILY MEDICINE

DELINEATION OF PRIVILEGES - FAMILY MEDICINE KALEIDA HEALTH Name DELINEATION OF PRIVILEGES - FAMILY MEDICINE LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency

More information

RESIDENT GOALS AND OBJECTIVES BY ROTATION U-2 U-2 (PGY-3,4) GOALS AND OBJECTIVES BY ROTATION.

RESIDENT GOALS AND OBJECTIVES BY ROTATION U-2 U-2 (PGY-3,4) GOALS AND OBJECTIVES BY ROTATION. RESIDENT GOALS AND OBJECTIVES BY ROTATION U-2 U-2 (PGY-3,4) GOALS AND OBJECTIVES BY ROTATION. The following G&O s are representative of the unique experience gained at the individual institutions and represent

More information

CARDIOVASCULAR SURGERY PHYSICIAN ASSISTANT CLINICAL PRIVILEGES

CARDIOVASCULAR SURGERY PHYSICIAN ASSISTANT CLINICAL PRIVILEGES Notice to Applicant: Applicants have the burden of producing information deemed adequate by University of Mississippi Medical Center (UMMC) for a proper evaluation of current competence, current clinical

More information

Patient Name: David Thomas Diagnosis: Cancer, Tracheostomy

Patient Name: David Thomas Diagnosis: Cancer, Tracheostomy Patient Name: David Thomas Diagnosis: Cancer, Tracheostomy Overview of Scenario Simulated Patient Overview Target Audience (Part A): 2 nd year Speech Pathology students, 2 nd year Social Work students

More information

Group Hospitalization and Medical Services, Inc.

Group Hospitalization and Medical Services, Inc. Group Hospitalization and Medical Services, Inc. doing business as CareFirst BlueCross BlueShield (CareFirst) 840 First Street, NE Washington, DC 20065 202-479-8000 A not-for-profit health service plan

More information

Interplast UK Mission to Holy Family Hospital, Rawalpindi,Pakistan 10th Sep - 23rd Sep 2016 Registered Charity Number

Interplast UK Mission to Holy Family Hospital, Rawalpindi,Pakistan 10th Sep - 23rd Sep 2016 Registered Charity Number Interplast UK Mission to Holy Family Hospital, Rawalpindi,Pakistan 10th Sep - 23rd Sep 2016 Registered Charity Number On Saturday 10th September the majority of the Interplast UK volunteers arrived at

More information

q' Clinical Privileges Update Form U~lVERSTY '!VRGNA Bhiken Naik Department of Anesthesiology HEALTH SYsTEM have reviewed the privileges previously granted to me and request the following changes to include

More information

GOALS AND OBJECTIVES

GOALS AND OBJECTIVES GOALS AND OBJECTIVES The goals of the Division of Otolaryngology Head and Neck Surgery are: 1. To provide the highest-quality patient care 2. To provide comprehensive education of residents and medical

More information

COURSE DESCRIPTIONS. Emergency Health Sciences (EMSP)

COURSE DESCRIPTIONS. Emergency Health Sciences (EMSP) ` COURSE DESCRIPTIONS Emergency Health Sciences (EMSP) EMSP 4010. Emer Med Serv-Ambulance. 4 Credit Hours. Orientation to the San Antonio Fire Department Standard Medical Operating Procedures (SMOPs) and

More information

Your Guide To Head & Neck Surgery

Your Guide To Head & Neck Surgery Your Guide To Head & Neck Surgery Singapore General Hospital Outram Road Singapore 169608 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted

More information

Partial glossectomy. Your operation explained. Information for patients Head and Neck Centre

Partial glossectomy. Your operation explained. Information for patients Head and Neck Centre Partial glossectomy Your operation explained Information for patients Head and Neck Centre page 2 of 12 This leaflet provides information about the procedure known as partial glossectomy. It explains what

More information

Pediatric Surgery Curriculum Clinical Base Year

Pediatric Surgery Curriculum Clinical Base Year Pediatric Surgery Curriculum Clinical Base Year Collaborating Faculty: Cindi Graves, MD Residency Program Director Department of Surgery Purpose and Educational Value The purpose of the Pediatric Surgery

More information

NEONATAL-PERINATAL MEDICINE CLINICAL PRIVILEGES

NEONATAL-PERINATAL MEDICINE CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for

More information

SUTTER MEDICAL CENTER, SACRAMENTO Department of Family Medicine Delineation of Privileges

SUTTER MEDICAL CENTER, SACRAMENTO Department of Family Medicine Delineation of Privileges To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any Request Privilege Appointment [ ] Admit [ ]

More information

PGY-7 (2 nd Year) GOALS AND OBJECTIVES VANDERBILT UNIVERSITY MEDICAL CENTER VASCULAR SURGERY PROGRAM ROTATION-BASED GOALS AND OBJECTIVES

PGY-7 (2 nd Year) GOALS AND OBJECTIVES VANDERBILT UNIVERSITY MEDICAL CENTER VASCULAR SURGERY PROGRAM ROTATION-BASED GOALS AND OBJECTIVES PGY-7 (2 nd Year) GOALS AND OBJECTIVES VANDERBILT UNIVERSITY MEDICAL CENTER VASCULAR SURGERY PROGRAM ROTATION-BASED GOALS AND OBJECTIVES A. VANDERBILT HOSPITAL VASCULAR SURGERY SERVICE COMPETENCY BASED

More information

OPHTHALMOLOGY CLINICAL SERVICE RULES AND REGULATIONS 2011

OPHTHALMOLOGY CLINICAL SERVICE RULES AND REGULATIONS 2011 OPHTHALMOLOGY CLINICAL SERVICE RULES AND REGULATIONS 2011 Approved by MEC February 3, 2011 OPHTHALMOLOGY CLINICAL SERVICES TABLE OF CONTENTS I. OPHTHALMOLOGY CLINICAL SERVICE ORGANIZATION... 2 A. SCOPE

More information

Review Process. Introduction. Reference materials. InterQual Procedures Criteria

Review Process. Introduction. Reference materials. InterQual Procedures Criteria InterQual Procedures Criteria Review Process Introduction As part of the InterQual Care Planning family of products, InterQual Procedures Criteria provide healthcare organizations with evidence-based clinical

More information

Effective Date. Patient Status Initial Inpatient Order. 1 of 5

Effective Date. Patient Status Initial Inpatient Order. 1 of 5 1 of 5 Effective Date The Admit Patient order has been redesigned to meet CMS guidelines. Effective May 8, 2012, three orders will replace the Admit Patient order: Patient Status Initial Inpatient Patient

More information

PROCEDURES PERFORMED

PROCEDURES PERFORMED PROCEDURES PERFORMED Dr. Rehnke regularly performs each of the surgical procedures listed here. You can be confident that the doctor is experienced and specially trained in each one. Our office staff is

More information

BENEFITS AVAILABLE IN TRICARE/CHAMPUS FOR CHILDREN WITH LIFE THREATENING ILLNESSES AND THEIR FAMILIES

BENEFITS AVAILABLE IN TRICARE/CHAMPUS FOR CHILDREN WITH LIFE THREATENING ILLNESSES AND THEIR FAMILIES APPENDIX 9 BENEFITS AVAILABLE IN TRICARE/CHAMPUS FOR CHILDREN WITH LIFE THREATENING ILLNESSES AND THEIR FAMILIES Respite Care BENEFIT CITATION DESCRIPTION OF BENEFIT Respite care TRICARE Extended Care

More information

Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule; Proposed Rule; CMS-1582-PN

Medicare Program; Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule; Proposed Rule; CMS-1582-PN July 25, 2011 Donald M. Berwick, MD Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1582-PN Mail Stop C4-26-05 7500 Security Boulevard Baltimore,

More information

Sample page. Orthopaedics: Hips & Below. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION

Sample page. Orthopaedics: Hips & Below. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION CODING COMPANION 2018 Orthopaedics: Hips & Below A comprehensive illustrated guide to coding and reimbursement POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.

More information

POLICY - RESIDENT SUPERVISION DEPARTMENT OF UROLOGY (2008) - Approved UTHSCSA GME 2009

POLICY - RESIDENT SUPERVISION DEPARTMENT OF UROLOGY (2008) - Approved UTHSCSA GME 2009 POLICY - RESIDENT SUPERVISION DEPARTMENT OF UROLOGY (2008) - Approved UTHSCSA GME 2009 Section I. Introduction The Urology Department has adopted the general supervision policy as provided by the UTHSCSA-GMEC.

More information

Read Valuable Advice For Best Results Of Any Cosmetic Procedure You Want.

Read Valuable Advice For Best Results Of Any Cosmetic Procedure You Want. SAM SPERON, M.D., F.A.C.S. Plastic & Reconstructive Surgeon MEMBER M OF THE AMERICAN A S SOCIETY FOR AESTHETIC PLASTIC SURGERY AMERICAN SOCIETY OF PLASTIC SURGEONS Learn 7 Critical Questions To Ask Any

More information

Sample page. General Surgery/ Gastroenterology. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION

Sample page. General Surgery/ Gastroenterology. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION CODING COMPANION 2018 General Surgery/ Gastroenterology A comprehensive illustrated guide to coding and reimbursement POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit

More information

All but Part A Deductible. Medicare Part A Deductible. Nothing. Inpatient Hospital All but Part A Medicare Part A Nothing.

All but Part A Deductible. Medicare Part A Deductible. Nothing. Inpatient Hospital All but Part A Medicare Part A Nothing. Summary of Signature 65 Benefits Signature 65 is a Medicare-complimentary benefit program that fills in the coverage gaps and cost sharing of the traditional Medicare program (Medicare Part A and ). In

More information

Eligibility Introduction Practice Ethics and Patient Rights and Responsibilities (RI)... 6

Eligibility Introduction Practice Ethics and Patient Rights and Responsibilities (RI)... 6 Table of Contents Eligibility... 2 Introduction... 3 Practice Ethics and Patient Rights and Responsibilities (RI)... 6 Provision of Care, Treatment, and Services (PC)... 8 Medication Management (MM)...

More information

Clinical Privileges Profile Pain Management. Kettering Medical Center System

Clinical Privileges Profile Pain Management. Kettering Medical Center System Printed Name Clinical Privileges Profile Pain Management Kettering Medical Center Sycamore Medical Center Kettering Medical Center System Applicant: Check off the Requested box for each privilege requested.

More information

The Staff shall be divided into Active, Ambulatory Proceduralists, Affiliate and Honorary Categories.

The Staff shall be divided into Active, Ambulatory Proceduralists, Affiliate and Honorary Categories. Medical Staff Bylaws New Category Proposal ARTICLE 4. CATEGORIES OF THE MEDICAL STAFF 4.1 CATEGORIES The Staff shall be divided into Active, Ambulatory Proceduralists, Affiliate and Honorary Categories.

More information

Coding Analysis Related to Commercialization of the XPANSION Skin Grafting Instruments Provided by The Institute for Quality Resource Management

Coding Analysis Related to Commercialization of the XPANSION Skin Grafting Instruments Provided by The Institute for Quality Resource Management The codes provided would be recognized as active payable codes by The Centers for Medicare and Medicaid Services (CMS) and private insurance as well. The payment amounts will vary for private insurance

More information