Form 0917-0009-7 0917-0009-7, Psychiatric Privileges Request Form

Circular Appendix 95–16–C.4 (04/10)
Page 5 of 5

Psychiatric PRIVILEGES REQUEST FORM

INTRODUCTION

This Psychiatric Privileges Request Form is designed primarily for physicians who have completed a residency in psychiatry; (psychiatric privileges for nonpsychiatric physicians are listed in section VII of the Medical Privileges Request Form). It must be accompanied or preceded by a completed application for medical staff appointment, including the necessary supporting documents. Many clinical privileges pertinent to the practice of psychiatry are listed below. The request for privileges must reflect both the applicant's and the facility/staff's ability to carry out or support the various functions. Any additional requested privileges shall be presented in an attached list and referenced on this form under “other.”

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 medical community at large. Be sure to sign the request as indicated on page 6.

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. Major General Psychiatric Privileges

A. Diagnosis and Treatment of Adult:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Affective disorders (unipolar& bipolar) and dysthymic disorders
2. Schizophrenic disorders (including brief reactive psychosis)
3. Anxiety disorders
4. Substance use disorders
5. Somatoform disorders
6. Personality disorders and borderline states
7. Other (specify):

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
B. Differential diagnosis of organic mental syndromes psychiatric, physical, by laboratory techniques
C. Differential diagnosis and treatment of neuropsychiatric conditions, including localizing and diffuse cortical pathology
D. Differential diagnosis and treatment of emergency psychiatric conditions, including suicidal, acutely psychotic, assaultive, noncommunicative, and drug and alcohol related syndromes

E. Adult Psychopharmacologic Use of:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Tricyclic antidepressants
2. Mono-amine oxidase inhibitors
3. Nonanaesthetic uses of neuroleptics
4. Benzodiazepines in the treatment of psychiatric disorders (especially anxiety)
5. Psychomotor stimulants
6. B-blockers for psychiatric use
7. Lithium carbonate or citrate for psychiatric uses
8. Differential diagnosis and treatment of sleep disorders

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
F. Diagnosis and treatment of psychosexual disorders and nonphysiologic sexual dysfunction
G. Individual psychotherapy of patients
H. Group psychotherapy
I. Family/couple therapy
J. Psychiatric program consultation
K. Psychiatric administrative consultation
L. Diagnosis and treatment of addiction and habituation to DEA schedule I through V drugs NOTE: Must conform to DEA regulations.
M. Other (specify):

II. Child Psychiatric Privileges

A. Diagnosis and Treatment in Children and Adolescents of:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Schizophrenia and related disorders
2. Affective disorders
3. Autism
4. Anxiety disorders
5. Personality disorders
6. Psychosexual disorders
7. Substance use disorders
8. Psychological factors affecting physical condition
9. Anorexia nervosa, bulimia, eating disorders
10. Conduct disorders
11. Attention deficit disorder and hyperactivity
12. Enuresis, encopresis, sleep walking, and sleep terror
13. Tics (including Tourette’s disorder)
14. Identity disorders
15. Attachment/object relations disorders
16. Other (specify):

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
B. Diagnosis and treatment of mental retardation
C. Diagnosis and treatment of developmental delays, learning disabilities, and specific neuropsychiatric dysfunctional syndromes

D. Use in Children and Early Adolescents of:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Antidepressants
2. Neuroleptics
3. Benzodiazepines
4. Psychomotor stimulants
5. Anticonvulsants for psychiatric purposes
6. Other medications with a primarily psychoactive pharmacologic effect
7. Other (specify):

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
E. Individual psychotherapy, play therapy, behavioral therapy, and common child therapy
F. Emergency child psychiatric diagnosis and treatment of more common emergency child psychiatric syndromes (e.g., suicide attempts, dissociative stages, psychotic presentations)
G. Other (specify):

III. Minor Psychiatric Privileges

A. Forensic Psychiatric Privileges in:

1. Civil proceedings:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
a. Adult
b. Child

2. Criminal proceedings:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
a. Adult
b. Child

B. Use of Legally Controlled Treatment Modalities, Including:	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Treatment of criminal sexual offenders
2. Use of electro-convulsive therapy
3. Use of investigational drugs in treatment of psychiatric disorders
4. Other (specify):

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
C. Diagnosis and treatment of epilepsy
D. Administration of individual psychological tests (e.g., MMPI, Bender, WAIS)
E. Treatment of chronic pain and illness behavior syndromes
F. Diagnosis/treatment of culture bound syndromes
G. Other (specify):

PSYCHIATRIC 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 60 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.