UNIVERSITY HOSPITAL
UROLOGY PHYSICIAN ASSISTANTS
REQUEST FOR PRIVILEGES
To be eligible to request clinical privileges, the following threshold criteria must be met.
EDUCATION: PA
TRAINING:
Successfully completed a physician assistants’ program is currently certified by the National Commission
on the Certification of Physician Assistants, and is authorized to practice by the State Composite Board of
Medical Examiners. Applicant must meet the requirements outlined in Allied Health Professional Policy and
Procedure MS-1.
EXPERIENCE:
Current demonstrated competence and an adequate level of current experience documenting the ability to
provide services at an acceptable level of quality and efficiency. All initial applicants at completion of
training must provide a letter of recommendation assessing performance from the Training Director.
All initial applicants beyond 12 months of training completion must provide a letter of recommendation
assessing performance from the hospital’s Chief of Staff, Department Chair, or Supervising Physician.
The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.
CORE PRIVILEGES: Functions under the supervision and general direction of his/her sponsoring physician.
Physician Assistants are licensed by the State of Georgia consistent with the Georgia State Medical Practice Act
and are permitted to perform medical acts consistent within the scope of their knowledge and accountability
and consistent with the governing practice of Physician Assistants in the Hospital.
(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing list
but rather reflective of the categories/types of privileges included in the core.)
REQUESTED GRANTED
Complete history and physical examination to be reviewed, approved and co-signed by the supervising physician.Document a clinical resume with the approving signature of the supervising physician.
Dictate procedural and clinical treatment summaries, except operative reports, when
personally participating in the clinical procedure or treatment.
Initiate physician prescription for medical treatment after discussion with and approval by
the supervising physician for such treatment.
Assist with patient clinical rounds of supervising physician’s patients & initiate approved
clinical activity.
Enter assessment of patient progress in the progress notes of the medical record to be
reviewed, approved and signed by the supervising physician.
Assist the physician in the review, collection & interpretation of clinical, diagnostic data
reports. Established physician protocols are to be utilized in subsequent prescriptions for
diagnostic studies.
Perform non-invasive clinical procedures and treatments consistent with supervising
physician’s protocols.
Participate in and institute patient education & discharge planning process.
Dictate discharge summaries in preparation for supervising physician’s review, approval
& signature.
Applicants requesting any other special privileges listed below must present documentation of training in
each privilege requested with a letter from the training director attesting to the applicant’s competence
and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff
and the Governing Board of University Hospital.
UROLOGY PHYSICIAN ASSISTANTS
REQUEST FOR PRIVILEGES
PAGE 2
SPECIAL PRIVILEGES to include: REQUESTED GRANTED
The applicant is required to submit a separate letter ofrequest for any privilege not included on this form.
______
Applicant’s Signature Date Applicant’s Printed Name
I hereby recommend that the above applicant be allowed to perform the duties and responsibilities listed above and/or on the separate, signed page, under my supervision as my Physician Assistant at University Hospital. I shall assume full responsibility for this individual’s training and actions in the procedures requested. (If the Physician Assistant will work for more than one physician in a group, each supervising physician must sign and date.) I also agree to abide by the Medical Staff’s Policy and Procedure regarding completion of competency evaluations as requested by the Medical Staff Office for my Allied Health Practitioner.
______
Supervising Physician’s Signature Date Physician’s Printed Name
______
Supervising Physician’s Signature Date Physician’s Printed Name
Revised 7/07