Optometric Privileges Request Form

Circular Appendix 95–16–C.7 (04/10)
Page 4 of 4

Optometric PRIVILEGES REQUEST FORM

INTRODUCTION

The Optometrist clinical privilege application must be accompanied, or preceded, by a completed application for medical staff appointment, including the necessary supporting documents. The most common privileges practiced by optometrists will be found in this document, but many may still have to be added by the applicant. This can be done by “writing in” additional privileges on the bottom of the page.

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item if privileges are requested. Be sure to sign the request as indicated on page 4.

Discipline-specific supervisor or area optometry consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location. This recommendation is considered by the privilege granting authority. Be sure to sign the request as indicated on page 4. Recommended limitations or denial of privileges must be explained in detail on an attached sheet.

Note: Any patient admitted to an IHS hospital for ocular procedures must have an admission history and physical exam conducted by a physician member of that hospital’s medical staff. Any non-ocular medical problem(s) present on admission, and any which occur during the hospital stay, must be evaluated and managed by a physician member of that hospital's medical staff.

Credentials as Evidence of Competency

I. CLASS I Optometric PRIVILEGES

A. Education

A degree of doctor of optometry is required from one of the schools or colleges of optometry listed as accredited by the Council on Optometric Education of the American Optometric Association (COEAOA).

B. Licensure

A full and unrestricted license is required to practice optometry in a State, a Territory, or the District of Columbia, if hired as a civil servant. A commissioned officer of the U.S. Public Health Service (USPHS) must meet the USPHS optometry appointment standards.

II. CLASS II Optometric PRIVILEGES

An optometrist is eligible for additional clinical privileges, if the following credentials are provided:

a. A license to practice optometry and a State certification to use therapeutic pharmaceutical agents.

b. If (a) is not satisfied, evidence of one or more of the following is required:

1. Training or experience such that the optometrist now holds IHS privileges or equivalent, consistent with appropriate portions of Class II privileges, and these privileges have been held and regularly reviewed over the prior two or more years.

2. Successful completion of at least 1 year of postgraduate training in a fellowship or primary care residency program accredited by the COEAOA.

3. Diplomate of the American Academy of Optometry in ocular disease in primary care.

4. Successful completion of a minimum 106-hour course in the management of ocular diseases and/or conditions as certified by an accredited optometric educational institution.

5. A passing score on a national certifying examination in the treatment and management of ocular diseases and/or conditions.

OPTOMETRY PRIVILEGES REQUEST FORM

I. Class I Optometric Privileges	Applicant Requests		Supervisor/ Consultant Recommends*
	Ltd.	Full	N.R.	Ltd.	Full
General optometric examination, diagnosis and optical therapy
Medical laboratory studies
Ocular imaging studies
Photo documentation
Diagnostic pharmaceutical agents
Extended posterior segment evaluation
Visual fields testing/evaluation
Low-vision management
Contact lens management
Oculomotor/perceptual/papillary problems
Non-invasive management of lid conditions
Non-invasive care of external eye injuries/burns
Epilation of lashes
Conjunctivitis therapy with topical medications
Lacrimal function evaluation (non-invasive)
Corneal abrasion care
Nonperforating foreign substance removal
Management of keratitis-sicca and other epithelial keratitis (non microbial)
Gonioscopy
OTC oral medications for ocular disease
Emergency treatment of life/sight threatening condition prior to referral
Other (specify):

*This person is always an optometrist.

II. Class II Optometric Privileges

The necessary pharmaceutical agents are approved to complete the indicated diagnostic/non-invasive therapeutic procedures for the following:

	Applicant Requests		Supervisor/ Consultant Recommends*
	Ltd.	Full	N.R.	Ltd.	Full
Ultrasound measurement/evaluation
Punctum dilation/plugs/irrigation
Anterior uveitis care
Medical hyphema management
Open angle glaucoma
Acute glaucoma
Lids and periorbital skin conditions
Keratitis
Episcleritis
Post-surgical eye care
Other (specify):

*This person is always an optometrist.

Optometry 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.

Service Unit O.D. or Date

Area Optometry Consultant

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.