Form 0917-0009-11 OMB 0917-0009-11, Psychology Privileges Request Form

Indian Health Service Medical Staff Credentials Application

Psychology_privileges_request_form[1]

Psychology

OMB: 0917-0009

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Circular Appendix 95–16–C.8 (04/10)
Page
4 of 4

Psychology PRIVILEGES REQUEST FORM

INTRODUCTION

This Psychology Privileges Request Form 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 psychology 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 clinical psychology community at large. Be sure to sign the request as indicated on page 4.

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. CLinical Attending Privileges

A. Patient Management Privileges

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Admit patients






  1. Discharge patients






  1. Coordinate/provide psychological care






  1. Write and sign treatment plans






  1. Write orders for assessment and treatment procedures






  1. Write orders for medical consultation






  1. Participate on multi-disciplinary treatment teams






  1. Enter consultation notes on charts






9. Other (specify):








B. Clinical Assessment Privileges

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Behavioral assessment






  1. Biobehavioral and psychophysiological assessment

exam­inations






  1. Neuropsychological examination






  1. Mental status examination






  1. Intellectual assessment






  1. Developmental assessment






  1. Personality assessment






  1. Trauma assessment






  1. Differential diagnostic assessment






  1. Forensic assessment






  1. Psychopharmacologic response monitoring






  1. Vocational/education assessment






  1. Psychosocial assessment






14. Other assessment, as indicated








C. Clinical Treatment Privileges

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Individual psychotherapy






  1. Group psychotherapy






  1. Family psychotherapy






  1. Behavior modification






  1. Hypnosis






  1. Biofeedback






  1. Emergency room/crisis intervention






  1. Pain management






  1. Substance abuse reduction






  1. Stress management






  1. Rehabilitation services






12. Other (specify):








II. Consulting Privileges

A. Within the Facility

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Consultation liaison to other services






  1. Organizational developmental services






  1. Staff development






  1. Wellness promotion








B. External to the Facility

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Professional and community education






  1. Community development






  1. Disease/injury prevention








III. Programmatic Activities

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Program planning and evaluation






  1. Collection/interpretation of caseload date






  1. Ascertainment of population mental health needs






  1. Supervise staff and trainees






  1. Ensure accreditation/approval










Psychology 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 10 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.





File Typeapplication/msword
File TitleCircular Appendix 95-16-C.8
SubjectPsychology Privileges
AuthorKennington Wall
Last Modified ByKennington Wall
File Modified2013-01-16
File Created2012-12-11

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