Delineation of Privilege Form
Specialty: Podiatry
Applicant: ______Date: ______
Initial Change in privileges Renewal of privileges
In order to request these clinical privileges the applicant must meet the following threshold criteria:
Basic Education: / DPMMinimum formal training: / Successful completion of accredited residency training program in podiatry.
Board Certification: / Current ABPOPPM Board Certification; or attain Board Certification within (5) years of completion of training program.
Reappointment: Maintenance of Board Certification required for reappointment eligibility.
Failure to maintain board certification within the required timeframe, or failure to maintain board certification, will result in automatic relinquishment of privileges.
Required Previous Experience:
(required for new applicants) / Recent residency or fellowship training experience.
Clinical References: / Training director (if training completed in the three years prior to application) or hospital where applicant has been affiliated in the past year; and three additional peer references who have recently worked with the applicant and directly observed his/her professional performance over a reasonable period of time and who will provide reliable information regarding current clinical competence, ethical character and ability to work with others.
Continuing Medical Education / Completed 48 hours of approved continuing education hours in the past 2 years.
Other / · Current, unrestricted license to practice medicine in the state of Nebraska
· Malpractice insurance in the amount of $1m/$3m (contractor or volunteer
· Current, unrestricted DEA certificate
· Ability to participate in federally funded program (Medicare or Medicaid)
Applicant: Place a check in the (R) column for each privilege Requested. (A) = Recommend Approval as Requested, (C) = Recommended w/ Conditions/Modifications or (N) Not Recommended. PLEASE NOTE: If conditions or modifications are noted, the specific condition and reason for same will be stated on the last page.
(R) / GENERAL PRIVILEGES – PODIATRY / (A) / (C) / (N)· Medical and surgical treatment of disorders of the foot. “The foot is defined to be the pedal extremity of the human body and its articulations, and shall include the tendons and muscles of the lower leg only as they shall be involved in the condition of the foot.”
· Comprehensive and complete podiatric medical examination for consultation, diagnosis, and treatment planning
· Biomechanical examination with fabrication or prescribing of orthotic and shoe appliances or devices, including design of special shoes
· Comprehensive joint and gait analysis as related to foot and ankle
· All dermatological diseases of the foot
· All circulatory disorders affecting the foot
· All neurological disorders affecting the foot
· Arthritis and other inflammatory diseases affecting the foot
· All toenail disorders
· Skin and soft tissue tumors and cysts of the foot
· Soft tissue surgery of the foot (including the skin and nails)
· Foot trauma
· Skin and soft tissue biopsy of the foot
· Treatment of closed extremity dislocations or simple fractures of foot and ankle
· Diagnostic and therapeutic procedures
· Order x-rays of the lower extremities.
· Order and interpret all appropriate laboratory studies in the practice of podiatric medicine and surgery
· Order and prescribe treatment by physical therapy
ADDITIONAL PRIVILEGES: A request for additional privileges not included on this form must be submitted to the Medical Director for review.
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Applicant’s Signature Date
Chief Medical Officer Approval: Date:
Date Temporary Privileges Granted:
Date Full Privileges Granted by Board:
Conditions/Modifications:
PRIVILEGE / MODIFICATION/CONDITION with explanationF:\CREDENTIALING\Forms\Delineation of Privilege Form - podiatry (draft).doc