Form 0917-0009-14 OMB No. 0917-0009-14, Radiolgy Privileges Request Form

Indian Health Service Medical Staff Credentials Application

Radiology_privileges_request_form[2]

Radiology

OMB: 0917-0009

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Circular Appendix 95–16–C.11 (04/10)
Page
4 of 4

RADIOLOGY PRIVILEGES REQUEST FORM

INTRODUCTION

The Radiology Privileges Request Form must be accompanied or preceded by a complete application for medical staff appointment, including the necessary supporting documents. Many clinical privileges pertinent to the practice of radiology are listed below. The request for privileges must reflect both the applicant’s and the facility’s/staff’s ability to carry out or support the various functions. Documentation of training and/or experience in performing various procedures/modalities must accompany this request. Any additional privileges may be requested on the form or may be presented in an attached list.

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item whether you are requesting either 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 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. This recommendation is considered by the governing body when granting or not granting privileges.

I. RADIOGRAPHIC EXAMINATIONS

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. General diagnostic roentgenology






  1. Barium studies, including small bowel enterolysis and

air-contrast barium enemas






  1. Intravenous pyelography






  1. Fistula and sinus tract studies






  1. Myelography (cervical, lumbar, & thoracic)






  1. Other (specify):








II. COMPUTERIZED TOMOGRAPHIC EXAMINATIONS

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Head (including temporal bone and pituitary)






  1. Neck (including salivary glands, and larynx)






  1. Chest






  1. Abdomen






  1. Pelvis






  1. Spine






  1. Extremities






  1. Other (specify):








III. Ultrasound

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Aortic sonography






  1. Obstetrical sonography






  1. Biophysical profile






  1. Gallbladder sonography






  1. Liver sonography






  1. Pancreatic sonography






  1. Splenic sonography






  1. Pelvic sonography






  1. Renal sonography






  1. Thyroid sonography






  1. Vascular sonography






  1. Deep venous (abd/extrem, etc.)






  1. Carotid






  1. Sonography of soft tissue masses or fluid collections






  1. Sonography for thoracentesis guidance






  1. Sonography for guidance of other needle aspiration or biopsy






  1. Sonography for placement of indwelling

catheters (nephrostomy, gall bladder)






  1. Other (specify):








IV. MAMMOGRAPHY

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

  1. Mammogram interpretation






  1. Needle localization for biopsy






  1. Galactography








V. SPECIAL PROCEDURES

Applicant Requests

Supervisor/ Consultant Recommends


Ltd.

Full

N.R.

Ltd.

Full

A. Abscess drainage






B. Drainage of fluid collections






C. Biopsy/fine needle aspirates






D. Arthrography:






1. Shoulder






2. Wrist






3. Knee






E. Percutaneous gallstone removal






F. Percutaneous nephrostomy tube placement






G. Percutaneous biliary drainage tube placement






H. Percutaneous transhepatic cholangiography






I. Venography






J. Other (specify):












RADIOLOGY 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.





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

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