Dental Privileges Request Form

Circular Appendix 95–16–C.6 (04/10)
Page 5 of 5

Dental PRIVILEGES REQUEST FORM

INTRODUCTION

The Dental Privileges Request Form must be accompanied or preceded by a completed application for medical staff appointment, including the necessary supporting documents. Most clinical privileges pertinent to the dental program of your assigned facility are listed below.

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item whether you are requesting limited or full privileges. Limited means that the applicant may function in the area of the stated clinical privileges only under the direct supervision of a provider holding full privileges. Full means that the applicant is entitled to function independently, following standards consistent with the dental community at large. Be sure to sign the request as indicated on page 5.

Discipline-specific supervisor or consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location for either full, limited, or not recommended (N.R.). Please explain any recommended limitations or denial of privileges on an attached sheet. Your recommendations are considered by the governing body when granting or not granting privileges.

I. ENDODONTIC PROCEDURES	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Anterior root canal therapy
B. Bicuspid root canal therapy
C. Molar root canal therapy
D. Endodontic surgery

II. Periodontics	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Mucogingival surgery
B. Osseous surgery
C. Osseous graft
D. Free soft tissue grafts
E. Splinting
F. Occlussal adjustment—limited
G. Occlussal adjustment—complete
H. Special periodontal appliances (occlussal guard)

III. Removable Prosthodontics	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Complete dentures
B. Immediate dentures
C. Partial dentures
D. Obturator for cleft palate
E. Overdenture—complete/partial
F. Special appliances (specify):

IV. Oral Surgery	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Routine tooth extractions
B. Surgical extraction—erupted tooth
C. Surgical extraction—tissue impaction
D. Surgical extraction—bone impaction
E. Surgical extraction—impaction requiring sectioning of tooth
F. Residual root recovery by surgery
G. Oral antral fistula closure
H. Antral root recovery
I. Tooth replantation
J. Tooth transplantation
K. Surgical exposure of impacted or unerupted tooth for orthodontic reasons
L. Surgical exposure of impacted or unerupted tooth to aid eruption
M. Biopsy of oral tissue (hard)
N. Biopsy of oral tissue (soft)
O. Alveoloplasty per quadrant in conjunction with extractions
P. Alveoloplasty per quadrant not in conjunction with extractions
Q. Stomatoplasty per arch—uncomplicated
R. Stomatoplasty per arch—complicated
S. Surgical excision
T. Destruction of lesion by physical methods (electrosurgery)
U. Removal of exostosis—maxilla/mandible
V. Incision and drainage of abscess (intraoral)
W. Incision and drainage of abscess (extraoral)
X. Removal of foreign body, skin, or subcutaneous alveolar tissue
Y. Maxilla closed reduction, teeth immobilized (if present)
Z. Mandible open reduction (intraoral)
AA. Mandible closed reduction
BB. Malar/zygomatic arch closed reduction
CC. Alveolus stabilization of teeth, open reduction, splinting
DD. Closed reduction of TMJ dislocation
EE. Frenulectomy
FF. Emergency tracheotomy
GG. Suturing of traumatic wounds (intraoral)
HH. Suturing of traumatic wounds (extraoral)

V. Orthodontics	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Removable appliance—maxillary arch
B. Removable appliance—mandibular arch
C. Fixed appliances—maxillary arch (minor tooth movement)
D. Fixed appliance—mandibular arch (minor tooth movement)
E. Functional appliances
F. Comprehensive orthodontic treatment

VI. Adjunctive Services	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. N2O analgesia
B. IV sedation
C. Therapeutic drug injection
D. Oral sedation

Dental PRIVILEGES REQUEST FORM

1. I hereby request the clinical privileges as indicated on the forms attached.

Applicant Date

2. I hereby recommend the clinical privileges as indicated.

Supervisor/Consultant Date

3. As Chairperson of the Medical Staff Executive Committee, I hereby recommend the clinical privileges: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Clinical Director Date

4. I hereby recommend the applicant for clinical privileges.

Service Unit Director Date

5. Privileges are hereby granted: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Chairperson of the Date

Governing Body

Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 20 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer, Indian Health Service, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852, ATTN: PRA (0917–0009). Please do not send this form to this address.