Clinical Privileging Application
Last Privileging Date: Expiration Date: Re-Privileging Date:
(*Two Years from last privileging date)
Granting, reviewing and changing of clinical privileges for the provider staff of LawndaleChristianHealthCenter will be in accordance with LawndaleChristianHealthCenterCredentialing & Privileging policy. Assignment of such clinical privileges are based upon education, clinical training, experience, demonstrated current competence, documented results of patient care, and other quality review monitoring deemed appropriate.
The principle of “documented competency” will prevail. Primary care medicine is a dynamic and comprehensive field. Privileges pertain to primary care specialties of family practice, pediatrics, internal medicine, general practice, and obstetrics/gynecology. LawndaleChristianHealthCenter also privileges dentists, optometrists, and other non-primary care specialties. The health center reserves the right to deny privileges to any physician or midlevel provider. The provider may appeal the decision according to the Credentialing & Privileging policy guidelines.
The privileges for the LawndaleChristianHealthCenter clinics will be granted in the following three classes. See separate form for dental, optometry and non-primary care privileging. It should be noted that a provider may be assigned to multiple classes.
CATEGORY ONE (Physician Assistant/Advanced Practice Nurse)
/Site Requested (Check all that apply)
O - OgdenH - Homan F - Farragut A - Archer
Illnesses or problems that may be complex and potentially life threatening, requiring skills acquired in successful completion of Nurse Practitioner or Physician Assistant training program. The provider is expected to recognize the limits of his/her capabilities and utilize consultants when problems are immediately life threatening, lie outside of, or are more complex than problems covered in the provider's training and accreditation.
CATEGORY TWO (Physician Residency/Board Certification)
(Check all that apply) General Practice Specialty /Site Requested (Check all that apply)
O - Ogden H - Homan F - Farragut A - Archer
Specialty:Illnesses or problems that may be complex and life threatening, requiring skills acquired in successful completion of a Family Practice, Pediatrics, Internal Medicine OB/GYN, and Radiology, ENT, Orthopedics, Neurology, or General Surgery Residency program. The provider is expected to recognize the limits of his/her capabilities and utilize consultants when problems lie outside of, or are more complex than problems covered in the provider's training and accreditation. May act as consultant* to others within his/her area of expertise.
CATEGORY THREE (Advanced Procedures/Subspecialty)
/Site Requested (Check all that apply)
O - OgdenH - Homan F - Farragut A - Archer
Illnesses or problems that may be complex and life threatening, requiring skills acquired in successful completion of a fellowship-training program. The provider is expected to recognize the limits of his/her capabilities and utilize consultants when problems are immediately life threatening, lie outside of, or are more complex than problems covered in the provider's training and accreditation. Will function as consultant* to others within his/her area of expertise
* A consultant is a practitioner who writes formal opinions in a chart or verbally provide recommendations in response to a request from another practitioner.
Provider Name: Start Date:
Degree: DO APN MD PA PhD Status (check): Staff Volunteer
Please Identify all specialty, subspecialties and certifications that you possess in the space below.Specialty: ______ Board Eligible Board Certified
Subspecialty or Certification: ______ Board Eligible Board Certified
Provider: Please initial next to each procedure under the column “Requested.”
Medical Director: Please initial next to each procedure requested in the appropriate decision column.
SCOPE OF PRACTICE
To be completed by the Medical DirectorDiscipline / Initials / Approved / Approved with Conditions
(see comments) / Denied / Site Designation
Family Practice
Internal Medicine
Obstetrics/Gynecology
Pediatrics
Other (circle): Radiology, General Surgery, ENT, Orthopedics
Procedure/Skills / Initials / Approved / Approved with conditions / Denied / Site DesignationPlease circle the site where procedure will be performed.
General
I&D of abscess / A F H O
Wart removal / A F H O
Cryotherapy / A F H O
Excision/biopsy of skin lesions / A F H O
Nail Removal / A F H O
Wound repair/suture / A F H O
Thoracentesis / A F H O
Aspiration of abscess, hematoma, cyst / A F H O
Pilonidal cyst removal / A F H O
Injection/drainage of ganglion cyst / A F H O
Bladder catheterization / A F H O
OB/Gyn/Women’s Health
Diaphragm fitting / A F H O
I&D of Bartholin's gland / A F H O
Colposcopy / A F H O
LEEP / A F H O
Endometrial Biopsy / A F H O
Endocervical Curretage Alone / A F H O
Word catheter placement / A F H O
Fine needle aspiration of breast lump / A F H O
Excision of breast lump, benign / A F H O
Norplant removal / A F H O
IUD insertion / A F H O
IUD removal / A F H O
Implanon insertion/removal / A F H O
Pessary/Other intravaginal support devices - fit and insertion / A F H O
Sono-hysterosalpingogram / A F H O
GI
Anoscopy / A F H O
Musculoskeletal
Splint/Cast application & removal / A F H O
Unna boot / A F H O
Intra-articular injection / A F H O
Injection therapy (IM/SQ) / A F H O
Joint aspiration / A F H O
Urology
Circumcision / A F H O
Vasectomy / A F H O
Other: / A F H O
Other: / A F H O
Important Note: While LCHC shall make every effort to maintain up-to-date, site specific privileges on all of its providers, a provider may at times be required to fill in for another provider at a site where he/she does not normally practice. In those exceptional situations, a provider will be considered privileged to perform procedures at that site and shall not need to update his/her privileging form. However, an update to the privileging form will be necessary if the provider begins regularly seeing patients at a site for which he/she is not privileged.
Supervisory/Collaborative comments regarding modification or denial.
Provider Signature:
/ Date:To be completed by Medical Director & Human Resources Only
ApprovalApproval, with Conditions
Disapproval
Medical Director:
/ Date:Human Resource Director:
/ Date:Board Member: / Date:
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