Form 0917-009-15 OMB No. 0917-0009-15, Pathology Privileges Request Form

Circular Appendix 95–16–C.12 (04/10)
Page 3 of 3

PathOLOGY PRIVILEGES REQUEST FORM

INTRODUCTION

The Pathology 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 pathology 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 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 3.

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.

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Autopsies: non-forensic
Intraoperative surgical pathology
Surgical pathology: microscopic examination, gross examination, and diagnosis with report
Cytology: microscopic examination and diagnosis, with report
Fine needle aspiration and biopsy: microscopic examination and diagnosis, with report
Bone marrow aspirate and biopsy: microscopic examination and diagnosis, with report
Muscle biopsy: light microscopic examination, and diagnosis, with report
Muscle biopsy: light microscopic immuno-cytochemistry and for electron microscopic examination and diagnosis, with report
Renal biopsy: light microscopic exam and diagnosis, with report
Renal biopsy: light microscopic, electron microscopic, immunocytochemistry examination and diagnosis, with report
Neuropathology: light microscopic exam and diagnosis, with report
Cytogenetic studies on tissues
Forensic pathology
Open lung biopsy: light microscopic exam and diagnosis with report
Open lung biopsy: light microscopic, electron microscopic and/or immunocytochemistry examination and diagnosis with report
Hematology and coagulation
Immunohematology consultation
Clinical chemistry consultation
Medical microbiology and parasitology consultation
Medical microscopy consultation
Serology and general immunology consultation

Pathology 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.