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 of
request for any privilege not included on this form.

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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.

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Supervising Physician’s Signature Date Physician’s Printed Name

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Supervising Physician’s Signature Date Physician’s Printed Name

Revised 7/07