Circular
Appendix 95–16–C.8 (04/10)
Page
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 |
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Ltd. |
Full |
N.R. |
Ltd. |
Full |
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9. Other (specify): |
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B. Clinical Assessment Privileges |
Applicant Requests |
Supervisor/ Consultant Recommends |
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Ltd. |
Full |
N.R. |
Ltd. |
Full |
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examinations |
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14. Other assessment, as indicated |
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C. Clinical Treatment Privileges |
Applicant Requests |
Supervisor/ Consultant Recommends |
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Ltd. |
Full |
N.R. |
Ltd. |
Full |
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12. Other (specify): |
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II. Consulting Privileges
A. Within the Facility |
Applicant Requests |
Supervisor/ Consultant Recommends |
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Ltd. |
Full |
N.R. |
Ltd. |
Full |
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B. External to the Facility |
Applicant Requests |
Supervisor/ Consultant Recommends |
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Ltd. |
Full |
N.R. |
Ltd. |
Full |
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III. Programmatic Activities |
Applicant Requests |
Supervisor/ Consultant Recommends |
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Ltd. |
Full |
N.R. |
Ltd. |
Full |
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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 Type | application/msword |
File Title | Circular Appendix 95-16-C.8 |
Subject | Psychology Privileges |
Author | Kennington Wall |
Last Modified By | Kennington Wall |
File Modified | 2013-01-16 |
File Created | 2012-12-11 |