Clinical Privileges Update Form
|
|
- Marcus Montgomery
- 5 years ago
- Views:
Transcription
1 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, or additional training necessary to perform new privileges. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type ofexperience): Current Privileges not to be Renewed:* r;p;i;ii;g;;""~~i"';~e;ed;r;";~tr;ported~;bei;g;~i~~t;rily~r;;ii;q"~i~hed~-~l~s"thi;"is"d;;;;hrle~y;~;;e";;;d;; i~;;s tig;t~~; lor, in return for not conducting an investigation or proceeding. Ifprivileges 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 atabank. As the ivision Head/QI Liaison and epartment ChairlMedical irector, we have reviewed the abovenamed related to privileges and agree that the above named clinician's qualifications are appropriate. Since ~e date of the last appointment, we have reviewed applicable information from the following sources of qualitj and utilization data: We findj's follows:. [_.V1~.Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as to the clinical staff with privileges as, but subject to a review in months. Should have clinical privileges granted but restricted as follows:, --::- ~~ Revised
2 Clinical Privileges Update Form llnlvei~sity qrvirginia Mark Mendelsohn epartment of Pediatrics 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. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type ofexperience): Current Privileges not to be Renewed: * ::';p~i~i~;liot renewed are not reported as being voluntarily relillq;i;hedllnless thi~i~d~ne while you are under i;;~~tigation; ;or, in return for not conducting an investigation or proceeding. Ifprivileges 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 atabank. CL~SIG:J~ As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed related to privileges and agree that the above 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 find 'follows: [2( Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as to the clinical staff with privileges as, but subject to a review in months.
3 Clinkal Privill:~gesUpdate Form Mendelsohn epartment of Pediatrics 'UM1VERSITY q!~vl,rg,inia ~I-ltl,11I1 I-lEALTH ~1 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. (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:*.~,., "'".w...._. '*Privileges not are not reported as being voluntarily relinquished unless this is done while you are under investigation; ~ or, in return for not conducting an investlgatlon or proceeding. If privileges are to be reported as voluntarily relinquished you 'will be notified and receive a copy ofthe report to be filed with the National Practitioner atabank. CLINICIAN SIGNATURE As the ivision Head/QI Liaison and epartment ChairlMedical irector, we have reviewed the abovenamed related to privileges and agree that the above 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: lli Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as to the clinical staff with privileges as, but subject to a review in months. EPARTMENT CHAIR SIGNATURE Revised
4 Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics U~1:VERSITY ".VIRGINIA 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. (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 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 ill be notified and receive a copy of the report to be filed with the National Practitioner atabank. As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed related to privileges and agree that the above 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 findtfollows: ~-~cceptable review with recommendation of reappointment to the clinical staff with clinical privileges as to the clinical staff with privileges as, but subject to a review in months. a~j~~ ~~~~~-- Should have clinical privileges granted but restricted as follows: _ ih A~..-, ilate l{. 23. a Revised 3/112006
5 Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes: 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 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 atabank As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed related to privileges and agree that the above 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: 10 Number: Patient/Family Morbidity/Mortality Satisfaction Reports Sentinel Events/Risk Management Reports Infection Reports Outpatient Clinical Practice Medical Records Reports Inpatient Attending Physician's Unscheduled rug Usage Reports Performance Health & Mental Status Readmissions We find as follows: ITAcceptable review with recommendation of reappointment to the clinical staff with clinical privileges as to the clinical staff with privileges as, but subject to a review in months. Should have clinical privileges granted but restricted as follows: _ ~t..-,r ~ :..j / crs~.'<20j HE LIAISON SIGNATURE I.~(~~ EPARTMENT CHAIR SIGNATURE RevisedlO/17/01
6 I ~ Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you be notified and receive a copy of the report to be filed with the National Practitioner atabank. As the ivision Head/QI Liaison and epartment ChairlMedical irector, we have reviewed the abovenamed related to privileges and agree that the above 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: 10 Number: PatienUFamily Morbidity/Mortality Satisfaction Reports Sentinel Events/Risk Management Reports Infection Reports Outpatient Clinical Practice Medical Records Reports Inpatient Attending Physician's Unscheduled rug Usage Reports We find as follows: Performance Health & Mental Status Readmissions ~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as ' to the clinical staff with privileges as, but subject to a review in mon s. Should have clinical privileges granted but restricted as follows:_--:f-_-f- -+--:I---r-,f-C:.,,- II / ~\TE IVISI HEA/QI LIAISON S GNATU -~(.~ EPARTMENT CHAIR SIGNATURE Revised I0/17/01
7 REQUEST FOR CLINICAL PRIVILEGES epartment of Pediatrics University of Virginia Health System Name ~..-:...~:...~:..:.J1L..._=_ _.!...:M...>..;~:::...~_'O_t_G~)\}.::..:. Medical School l--'- ~_n_ \,,_1 _~j,;-. ry\----!...:...),-d_o_v"_y_~ _-_c_.: \\,;,...,..1_---:-_----:----,- ivision G- {V\ ~rc--r, _'\1...:...k_,...,..._~..:...\'- ~ Year of Graduation I Cj g ~ Residency/Fellowship Institution 1. LA.--VA Training: Specialty PI-I) Co 1-0 vj Year 2. _ 3. _ Board/Sub Board Certification: () Specialty 1. I {...lc /1" ~. J Year Certified jcff'7 1)17[, 2. _ 3. _ Admitting Privileges? tlves o No PLEASE MARK AS REQUESTE ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNE TO PRACTICE; EMERGENCY PRIVILEGES SHOUL BE MARKE WHERE YOU ARE THE ESIGNATE PERSON TO COVER AN AREA IN WHICH YOU O NOT REGULARLY PRACTICE. AREAS IN WHICH YOU O NOT REGULARLY PRACTICE SHOUL BE LEFT BLANK. / I. MEICAL. GeneraI Pdt e ra rtc PnVI eges. The minimal requirement is completion of a Pediatric Residency In an accredited Pediatric residency program and certification by the American Board of Pediatrics or equivalent. Subspecialty Privileges (all require General Pediatric Privileges). The minimal requirement is completion of an accredited subspecialty residency (or equivalent as approved by ivision Head and epartment Chair). within 2 years for Pediatric Cardiology Pediatric diagnostic cardiac catheterization Includes right and left heart catheterization, angiocardiography, and balloon atrial septostomy, and myocardial biopsy. Requires pediatric cardiology certification and performance of > 30 cases/year. I +-, Interventional pediatric catheterization Includes ballon valvuloplasty, ballon angioplasty, intracardiac and intravascular stent placement, and therapeutic vessel or defect occlusion. Requires pediatric cardiology certification, dlaqnostic cardiac catherization 1
8 ,- privileges, evidence of formal instruction, performance of at least 10 cases with supervision, and annual performance of > 20 cases/year. Neonatology (required for Neonatal Intensive Care Unit Attending) ECMO (requires ECMO training and approval by ECMO Medical irector) Pediatric Endocrinology Pediatric Hematology/Oncology Bone marrow aspiration, biopsy, and harvest; hematopoietic stem cell reconstitution: Requires performance of 7 procedures under supervision of physician with these privileges. Pediatric Allergy Pediatric Critical Care (required for Pediatric Intensive Pediatric Nephrology Pediatric Ftheumatology Pediatric Infectious isease Pediatric Gastroenterology Pediatric endoscopy, and Immunology Pediatric Pulmonology Pediatric bronchoscopy Pediatric Genetics evelopmental/behavioral Additional Privileges Conscious sedation Pediatrics liver biopsy Swan-Ganz catheter placement Care Attending) -L b -0 /'11 j~ ~ Clinician Signature ~L:;J{}nJNJ Print Name: ivision Head Approval New Appointment I have reviewed this request for clinical privileges and approve it based on the applicant's training and experience. Print Name Signature ate Re-appointment I have reviewed this request for clinical privileges and approve it based on my personal observation of the applicant's clinical performance and the following ivision-based quality data: 5 ~\-6'), ~, Ch.,v-+r~u\ ew Print Name ate 2
9 \-o;~rtment Credentials Committee I :he Pediatric Credentials Committee has reviewed this appli 'univer:t~~ :;ia Healthsyste: 7approvest e requ Print Name epartment Chah'/Medical irector I have reviewed this application for clinical privileges and recommend appointment/reappointment to the Clinical Staff with the above described privileges. Print Name Signature ate clin_pri.ped R:
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 informationUPMC 1 Delineation of Privileges Request Criteria Summary Sheet. Facility: UPMC Shadyside. Specialty: MEDICINE
1 Facility: Shadyside Specialty: MEDICINE KNOWLEDGE Successful Completion of an ACGME/AOA, accredited program TRAINING The successful completion of an approved (ACGME/AOA) post graduate residency program
More informationPediatric Cardiology 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 informationPediatric Hematology/Oncology/HSCT 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~ ~..._..._...~..._ 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 informationPrivileges 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 informationDELINEATION OF PRIVILEGES - PEDIATRICS AND PEDIATRIC SUBSPECIALTIES
KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - PEDIATRICS AND PEDIATRIC SUBSPECIALTIES The responsibility of Pediatrics begins with the newborn and continues through 21 years of age. There are special
More informationGeneral Internal Medicine Clinical Privileges REAPPOINTMENT Effective from July 1, 2015 to June 30, 2016
Name: Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants must meet the following requirements as approved by the governing body, effective: 04/Jun/2013. Applicant:
More informationMD or DO or equivalent International medical training
UPMC 1 Delineation of Privileges Request Criteria Summary Sheet Facility: Specialty: Childrens Hospital of Pittsburgh of UPMC, North PEDIATRICS KNOWLEDGE MD or DO or equivalent International medical training
More informationPEDIATRIC CARDIOLOGY CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 08/05/2015. Applicant: Check off the Requested box for
More informationUNM SRMC Nephrology Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors, effective August 213, 2017 Initial Privileges (initial appointment) Renewal of Privileges (reappointment)
More informationPhysician Application
CONTROLLED RISK INSURANCE COMPANY OF VERMONT, INC. (A RISK RETENTION GROUP) CONTROLLED RISK INSURANCE COMPANY, LTD. Physician Application Please type or print responses in ink, and answer all questions
More informationLoma Linda University Medical Center Loma Linda, CA MEDICINE SERVICE PRIVILEGE FORM. Specialty: Page 1 of 15
Specialty: Page 1 of 15 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)
More informationProvider Profile GENERAL DETAILS STATE/ PROVINCE: OTHERS (PLEASE SPECIFY): CONTACT DETAILS DESIGNATION NAME PHONE MOBILE
Provider Profile Dear Valued Provider, Kindly fill up this form with the information requested below. Availability of accurate and detailed information about your facility will definitely help QLM staff
More informationAPP 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 informationINTERNAL 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 informationCRITERIA 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 informationCARDIOVASCULAR 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 informationX 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 informationUNMH Gastroenterology Clinical Privileges
o Initial privileges (initial appointment) o Renewal of privileges (reappointment) o Expansion of privileges (modification) All new applicants must meet the following requirements as approved by the UNMH
More informationSPECIALTY 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 informationNEPHROLOGY 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 informationNEONATAL-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 informationPEDIATRIC 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., 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 informationThe 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 informationinterchange Provider Important Message
HUSKY Health Primary Care Increased Payments Policy In accordance with Provider Bulletin PB14-75, certain primary care providers are eligible to receive increased Medicaid payments for primary care services
More informationPULMONARY 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 informationRegions Hospital Delineation of Privileges Pathology
Regions Hospital Delineation of Pathology Applicant s Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic formal training requirements
More informationDEVELOPMENTAL-BEHAVIORAL PEDIATRICS 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 informationPediatric Critical Care Fellowship Program
Pediatric Critical Care Fellowship Program Accredited by the Indian Society of Critical Care Medicine : Pediatric Critical Care Council & The Intensive Care Chapter of the Indian Academy of Pediatrics
More informationMedical Staff Services (509) ; Fax (509)
Medical Staff Services (509) 249-5327; Fax (509) 575-8775 Thank you for your interest in appointment to the Medical Staff of Virginia Mason Memorial (formerly Yakima Valley Memorial Hospital). At Memorial
More informationPerinatal Designation Matrix 3/21/07
Codes: N = Neonatal Criteria M= Maternal Criteria P= Perinatal Criteria (both N & P) Perinatal Designation Matrix 3/21/07 Service/ 1. (N) Minimum NICU bed capacity Minimum of 10 NICU beds. Minimum of 15
More informationPEDIATRIC PULMONOLOGY 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 informationFAMILY 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 informationPlease return your completed materials to: Duke University Medical Center Box 3417 Durham, NC 27710
Thank you for your interest in the with the Child and Adolescent Life Program. Our internship program is offered two times a year: Fall (September-December) and Spring (January April) To be qualified for
More informationUNMH Pediatric Nephrology Clinical Privileges
ll 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 informationUNM SRMC NURSE PRACTITIONER (NP) & LICENSED INDEPENDENT PRACTITIONER (LIP) CLINICAL PRIVILEGES. Name: Effective Dates:
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 informationPatient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult
Title: Documentation of Clinical Activities by UNMH Medical Staff and House Staff Applies To: UNM Hospitals Responsible Department: Office of Clinical Affairs Updated: 05/2016 Policy Patient Age Group:
More informationPROVIDER PARTICIPATION REQUEST FORM
PROVIDER PARTICIPATION REQUEST FORM Thank you for your interest in becoming a participating provider with Quartz. Your request will be evaluated for participation in all Quartz affiliate networks. In order
More informationMed/Peds Trainee Milestones and Goals and Objectives for Promotion Protocol for when to Call Faculty Johns Hopkins Hospital
Med/Peds Trainee Milestones and Goals and Objectives for Promotion Protocol for when to Call Faculty Johns Hopkins Hospital PGY 1 Interns should have close supervision by a resident and/or attending and
More informationPrivileges for San Francisco General Hospital
Applicant: Please initial the privileges you are requesting in the Requested column. Service Chief: Please initial the privileges you are approving in the Approved column. MedGI GASTROENTEROLOGY 2008 (0808
More informationPenrose-St Francis Hospital
Advanced Practice Nurse Please check applicable credential [ ] Nurse Practitioner [ ] Clinical Nurse Specialist [ ] Certified Nurse Midwife [ ] Certified Registered Nurse Anesthesist Area of focus _ ***************************************************************
More informationAPP PRIVILEGES IN UROLOGY
APP PRIVILEGES IN UROLOGY Education/Training Licensure Required Qualifications Successful completion of a PA or NP program Current Licensure as a PA or RN in the state of CA Current certification as a
More informationREVIEW OF PAEDIATRIC INPATIENT SERVICES AT ROYAL ALEXANDRA HOSPITAL
REVIEW OF PAEDIATRIC INPATIENT SERVICES AT ROYAL ALEXANDRA HOSPITAL 1. Introduction In 2012 there was a proposal by the Women and Children s Services Directorate to move the Paediatric Inpatient Services
More informationAPP PRIVILEGES IN RADIATION ONCOLOGY
APP PRIVILEGES IN RADIATION ONCOLOGY 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
More informationCh. 138 CARDIAC CATHETERIZATION SERVICES CHAPTER 138. CARDIAC CATHETERIZATION SERVICES GENERAL PROVISIONS
Ch. 138 CARDIAC CATHETERIZATION SERVICES 28 138.1 CHAPTER 138. CARDIAC CATHETERIZATION SERVICES Sec. 138.1 Principle. 138.2. Definitions. GENERAL PROVISIONS PROGRAM, SERVICE, PERSONNEL AND AGREEMENT REQUIREMENTS
More informationCriteria for granting privileges:
SPECIALTY OF NURSE PRACTITIONER Provider-based Clinic (PBC) Delineation of Clinical Privileges (DOP) Criteria for granting privileges: Current national board certification in the appropriate advanced practice
More informationAPP PRIVILEGES IN NEUROSURGERY
APP PRIVILEGES IN NEUROSURGERY Education/Training Licensure (Initial and Reappointment) Required Successful completion of a PA, NP or CNS program Current Licensure as a PA, RN or CNS in the state of CA
More informationDescriptions: Provider Type and Specialty
Descriptions: Provider Type and Specialty PROVIDER TYPE/SPECIALTY ADULT PRIMARY CARE Provides care for adults by treating common health problems, performing check-ups and providing prevention services.
More informationRheumatology 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 informationUNM SRMC CRITICAL CARE PRIVILEGES
UNM SRMC INSTRUCTIONS All new applicants must meet the following requirements as approved by the UNM SRMC Board of Directors effective May 24, 2017 Applicant: Check off the "Requested" box for each privilege
More informationGENETICS 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 informationRegions Hospital Delineation of Privileges Nephrology
Regions Hospital Delineation of Privileges Nephrology Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic
More informationDELINEATION OF PRIVILEGES - ANESTHESIOLOGY
KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - ANESTHESIOLOGY PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications
More informationMedical Genetics Clinical Privileges REAPPOINTMENT Effective from July 1, 2015 to June 30, 2016
Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants must meet the following requirements as approved by the Health Authority or Hospital, effective: 11/Dec2014.
More informationNURSE PRACTITIONER SCOPE OF PRACTICE
NURSE PRACTITIONER SCOPE OF PRACTICE Name of Nurse Practitioner (Print) Department DEFINITION A nurse practitioner is defined by law as someone who is registered with the New York State Education Department
More informationq' 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 informationNURSE 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 informationClinical 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 informationAPP 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 information2014 Accreditation Report The University of Kansas Medical Center
2014 Report s current of Degree and Certificate Programs Audiology - AUD GR Council on Academic in Audiology and Speech-Language Pathology (CAA) Cont. Accred. 2009 8 years 2016 Clinical Laboratory Sciences
More informationRegions Hospital Delineation of Privileges Critical Care
Regions Hospital Delineation of Privileges Critical Care Applicant s Name: Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic
More information2001 AAPA Physician Assistant Census Report 1. Respondents % Male % Female %
1 Section I. Personal Characteristics of Respondents* Table 1. Distribution of Respondents by Sex Respondents... 19786 100.0% Male... 8603 43.5% Female... 11183 56.5% Table 2. Distribution of Respondents
More informationUNM 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 informationTable 4.2c: Hours Worked per Week for Primary Clinical Employer by Respondents Who Worked at Least
CONTENTS INTRODUCTION HIGHLIGHTS OF NATIONAL STATISTICS SECTION 1: CHARACTERISTICS OF 2009 AAPA CENSUS RESPONDENTS Table 1.1: Number and Percent Distribution of Census Respondents by State Where Employed...
More informationSCOPE OF PRACTICE. Internal Medicine Residency USF Health Morsani College of Medicine University of South Florida
SCOPE OF PRACTICE Internal Medicine Residency USF Health Morsani College of Medicine University of South Florida Background Internal Medicine Residency is clinical training in a supervised environment
More information53. MASTER OF SCIENCE PROGRAM IN GENERAL MEDICINE, UNDIVIDED TRAINING PROGRAM. 1. Name of the Master of Science program: general medicine
53. MASTER OF SCIENCE PROGRAM IN GENERAL MEDICINE, UNDIVIDED TRAINING PROGRAM 1. Name of the Master of Science program: general medicine 2. Providing the name of level and qualification in the diploma
More informationPediatrics. Pediatrics Profile
Updated March 2018 Click on any of the contents below to navigate to the slide. Please click the home icon located at the top right of each slide to return to the table of contents slide. TABLE OF CONTENTS
More informationADOLESCENT MEDICINE CLINICAL PRIVILEGES
Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 06/03/15 Applicant: Check off the Requested box for each
More informationCLINICAL PRIVILEGES- PEDIATRIC ACUTE CARE NURSE PRACTITIONER
Name: Page 1 Initial Appointment Reappointment Department Specialty Area All new applicants must meet the following requirements as approved by the governing body effective: 09/16/15 Applicant: Check off
More informationDETROIT MEDICAL CENTER DEPARTMENT OF PSYCHIATRY DELINEATION OF PRIVILEGES IN PSYCHIATRY
DETROIT MEDICAL CENTER DEPARTMENT OF PSYCHIATRY DELINEATION OF PRIVILEGES IN PSYCHIATRY Applicant Name: QUALIFICATIONS: Effective July 1, 2009, all new applicants to the DMC will be required to be board
More informationRegions 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 informationPROVIDER NETWORK ADEQUACY INSTRUCTIONS
PROVIDER NETWORK ADEQUACY INSTRUCTIONS MANAGED CARE SYSTEMS PROVIDER NETWORK ADEQUACY INSTRUCTIONS Minnesota Department of Health Managed Care Systems PO Box 64882, St. Paul, MN 55164-0882 651-201-5100
More information2015 Physician Licensure Survey
2015 Physician Licensure Survey 1. What is your racial background? Please select all that apply. White American Indian or Alaska Native Native Hawaiian/Pacific Islander Black or African American Asian
More informationCME Needs Assessment Summary 2015
2 Creation Date: 1/11/217 Time Interval: 8/24/2 to 12/24/2 Total Respondents: 95 1. How do you utilize CME? 1 8 6 4 1. Provide information to patients 34 38% 2. Put new knowledge into practice 57 63% 3.
More informationAPP PRIVILEGES IN OTOLARYNGOLOGY
APP PRIVILEGES IN OTOLARYNGOLOGY 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
More informationCELLULAR THERAPY PRODUCT COLLECTION, PROCESSING, AND ADMINISTRATION DOCUMENT SUBMISSION REQUIREMENTS
CELLULAR THERAPY PRODUCT COLLECTION, PROCESSING, AND ADMINISTRATION DOCUMENT SUBMISSION REQUIREMENTS FACT-JACIE International Standards for Cellular Therapy Product Collection, Processing and Administration,
More information2009 AAPA Physician Assistant Census National Report
Report # CENS2009-01 January 2010 2009 AAPA Physician Assistant Census National Report Introduction The American Academy of Physician Assistants (AAPA) was founded in 1968 and is the only national organization
More informationMEMORANDUM OF AGREEMENT Between
MEMORANDUM OF AGREEMENT Between THE UNIVERSITY OF VERMONT MEDICAL CENTER (UVMMC) AND VERMONT FEDERATION OF NURSES AND HEALTH PROFESSIONALS (VFNHP) LOCAL 5221, UPV/AFT, AFL-CIO Medical Group RN Nursing
More information2018 Fall Medical Research Application
2018 Fall Medical Research Application Instructions This application is for medical research related requests only. This includes medical research studies, medical animal research studies, and medical
More informationCLINICAL PRIVILEGES- WOMEN S HEALTH NURSE PRACTITIONER
Name: Page 1 Initial Appointment Department Reappointment Specialty All new applicants must meet the following requirements as approved by the governing body effective: March 4, 2015. Applicant: Check
More informationChildren s Hospital Association Summary of Final Regulation. November 9, 2012
Medicaid Program; Payment for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration under the Vaccine for Children Program Children s Hospital Association Summary
More informationUNMH Critical Care Clinical Privileges. Name: Effective Dates: From To
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective November 17, 2016: INSTRUCTIONS: Applicant: Check off the requested box for each privilege requested.
More informationUNIVERSAL PROTOCOL POLICY FOR CORRECT SITE IDENTIFICATION (VERIFICATION OF CORRECT SITE FOR INVASIVE, HIGHRISK, OR SURGICAL PROCEDURES)
UNIVERSAL PROTOCOL POLICY FOR CORRECT SITE IDENTIFICATION (VERIFICATION OF CORRECT SITE FOR INVASIVE, HIGHRISK, OR SURGICAL PROCEDURES) PURPOSE: To promote patient safety by providing guidelines for verification
More informationCRITICAL CARE CLINICAL PRIVILEGES St. Dominic Jackson Memorial Hospital
PRINTED NAME: DATE: All new applicants must meet the following requirements as approved by the governing body, effective: 02/25/2016 INSTRUCTIONS Applicant: Check the requested box for each privilege requested.
More informationRegions Hospital Delineation of Privileges Nurse Practitioner
Regions Hospital Delineation of Privileges Nurse Practitioner Applicant s Last First M. Instructions: Place a check-mark where indicated for each core group you are requesting. Review education and basic
More informationRegions Hospital Delineation of Privileges Pulmonary Medicine
Regions Hospital Delineation of Privileges Pulmonary 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 informationBYLAWS TABLE OF CONTENTS DEFINITIONS 4 ARTICLE I. NAME AND PURPOSE 4
BYLAWS TABLE OF CONTENTS DEFINITIONS 4 ARTICLE I. NAME AND PURPOSE 4 ARTICLE II. MEDICAL STAFF MEMBERSHIP 4-5 2.1. MEDICAL STAFF MEMBERSHIP 5 2.2. QUALIFICATIONS FOR MEMBERSHIP 5 2.3. CONDITIONS AND DURATION
More informationClinical Assistant Program
Committee Policy s must assure uniform standards of qualification and a minimum level of competency for all clinical assistants. Program goals and objectives include: ensuring a standardized accountability
More informationRoles, Responsibilities and Patient Care Activities of Residents. Pediatric Nephrology Fellowship Program. Seattle Children s Hospital
Roles, Responsibilities and Patient Care Activities of Residents Pediatric Nephrology Fellowship Program Seattle Children s Hospital Definitions Resident: A physician who is engaged in a graduate training
More informationMartin s Point US Family Health Plan Pre-Authorization Requirements
Martin s Point US Family Health Plan Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete
More informationA comprehensive reference guide for Aetna members, doctors and health care professionals Aetna Institutes of Quality facilities fact book
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions A comprehensive reference guide for Aetna members, doctors and health care professionals Aetna Institutes of
More informationREQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES
REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES *Applicant Printed Name: *Denotes required fields (Last) (First) (M.I) (Degree) Maiden Name (Alias): (Last) (First) *DOB: *SSN Sex: Male Female *Applicant
More informationJOINT RULES AND REGULATIONS OF THE MEDICAL STAFF OF MEMORIAL REGIONAL HOSPITAL, MEMORIAL REGIONAL HOSPITAL SOUTH, AND JOE DIMAGGIO CHILDREN S HOSPITAL
JOINT RULES AND REGULATIONS OF THE MEDICAL STAFF OF MEMORIAL REGIONAL HOSPITAL, MEMORIAL REGIONAL HOSPITAL SOUTH, AND JOE DIMAGGIO CHILDREN S HOSPITAL AND THE MEDICAL STAFF OF MEMORIAL HOSPITAL PEMBROKE
More informationInfectious Diseases Elective PL1 Residents
PL1 Residents The elective rotation for residents in Pediatric Infectious Disease provides a broad learning experience for residents at all levels of training through provision of care for children requiring
More informationCLINICAL PRIVILEGES- PEDIATRIC SEDATION SERVICE APP
Name: Page 1 Initial Appointment Reappointment Department Specialty Area All new applicants must meet the following requirements as approved by the governing body effective: 8/7/2013 Applicant: Check off
More informationCME Needs Assessment Summary
216-217 Creation Date: 1/11/217 Time Interval: 7/28/216 to 12/5/216 Total Respondents: 73 1. How do you utilize CME? 1 8 6 4 1. Provide information to patients 29 41% 2. Put new knowledge into practice
More informationDEPARTMENT OF MEDICINE
Rules & Regulations Page 1 DEPARTMENT OF MEDICINE RULES AND REGULATIONS ARTICLE I - Name The name of this clinical department shall be the "Department of Medicine" of the Medical Staff of Washington Adventist
More informationSUPERVISION POLICY. Roles, Responsibilities and Patient Care Activities of Subspecialty Residents (Fellows)
Roles, Responsibilities and Patient Care Activities of Subspecialty Residents (Fellows) Definitions Pediatric Critical Care Medicine Fellowship Program Seattle Children s Hospital and Harborview Medical
More information