CHARTER TECHNICAL ADVISORY GROUP INDIAN HEALTH SERVICE
Sec.
1. Purpose
2. Goals
3. Membership
4. FIRST CLASS
5. Relationships
6. Meetings
7. Reports
8. Funding
1. Purpose. The Technical Advisory Group (TAG) provides leadership
to the Indian Health Service (IHS) Headquarters support staff so they
can carry out the IHS mission.
2. Goals. TAG was established in order to:
A. Ensure quality performance by all support staff by providing
leadership to the training and development programs.
B. Serve as advocates for support staff needs and opportunities.
C. Provide a professional interface between management and support
staff.
D. Motivate the support staff to reach their highest possible level
of performance.
E. Develop materials as references and guidelines to improve the
quality of support staff products.
3. Membership. The TAG is chaired by the secretary to the Director,
IHS, and is composed of the secretaries to each Associate Director.
When a designated secretary is unable to represent the office, an
alternate may be appointed by the Associate Director.
4. FIRST CLASS. FIRST CLASS is the identifier and logo for training
for IHS support staff that is sponsored by the TAG. The TAG has
developed and has proprietary use of the FIRST CLASS identifier.
5. Relationships.
A. To the Executive Staff:
The relationship between the TAG and the Executive Staff is critical
to the successful achievement of their goals. The effectiveness of TAG
is dependent upon the support of the Executive Staff in promoting TAG
programs with the Division Directors and the support staff within their
offices. Primary communication is between the Director of Headquarters
Operations and the TAG chairperson. Equally important communication
occurs between each Associate Director and his/her lead secretary.
B. To the Office of Human Resources:
The Training Branch within the Office of Human Resources is
responsible for carrying out the training and development programs for
the TAG. The Branch Chief is an ex-officio member of the TAG and meets
at least twice a year with the full group to review the upcoming fiscal
year training offerings and to evaluate the programs in progress.
C. To the Executive Secretariat:
The Director, Executive Secretariat (ES), is an ex officio member of
the TAG and shall meet with the TAG group at least twice a year to
maintain a liaison relationship with the TAG, and to present updated
correspondence information and materials. The Director, ES, will work
closely with the TAG chairperson and will be available to address issues
or concerns brought before the TAG.
6. Meetings. The TAG meets twice each month or at the call of the
chairperson during regular work hours. They also conduct a 2-day
retreat in the fall of each year to assess their progress and establish
their objectives for the upcoming year.
7. Reports. The TAG will meet annually with the Director of
Headquarters Operations and the Associate Directors to report on
progress toward objectives and activities. Feedback from this meeting
will be incorporated into the planning for the following year.
8. Funding. The TAG activities are funded through the Director's
office account. The training activities that are sponsored by the TAG
are included in the Headquarters training budget.
/s/MICHEL E. LINCOLN
Michel E. Lincoln
Acting Director
August 27, 1993
DISTRIBUTION: PSD 557 (Indian Health Mailing Key)
CIRCULAR NO. 93-5
IHS CIRCULARS
Indian Health Service Fiscal Intermediary Quality of Care Screens and
Followup Procedures
Sec.
1. Purpose
2. Background
3. Definitions
4. Policy
5. Responsibilities
6. Reporting Requirements
7. Effective Date
1. PURPOSE. This circular describes the policies and procedures of
the Indian Health Service (IHS) for managing potential quality of care
issues identified through Fiscal Intermediary (FI) screens or edits.
2. BACKGROUND. The IHS contract health services (CHS) program
authorizes payment for health care services that the IHS cannot provide
through its direct care system. An FI, currently the New Mexico Blue
Cross/Blue Shield Insurance Company, pays providers for these services.
As part of the payment review process, the FI identifies potential
quality of care issues. These issues are identified through the use of
sentinel event screens established by the IHS Clinical Advisory Group
(CAG). This circular outlines the disposition by the IHS of potential
quality of care issues raised by the FI.
3. DEFINITIONS.
A. Fiscal Intermediary - an organization under contract with the IHS
that undertakes to validate and pay CHS claims.
B. Quality of Care Issue - medical information discovered by the FI
during the process of validating and paying medical bills that may
reflect upon the standard of care rendered to the IHS beneficiary by the
provider.
C. Managed Care Committee - a committee, established by the
Director, to plan, develop, promote, and institute the principles of
managed care and assure maximum access to quality health services
throughout the IHS.
D. Clinical Advisory Group - A group of four senior IHS physicians
appointed by the IHS to review medical care problems identified by the
FI, and to act as an advisory group to the IHS on monitoring the quality
of medical care provided by the private sector that is paid by the FI.
4. POLICY. This policy applies to all CHS claims paid through the
FI.
5. RESPONSIBILITIES.
A. FISCAL INTERMEDIARY.
The FI shall:
(1) Institute a system of editing to allow for the post-payment
review of quality of care issues, with direction from the CAG (see
5.A.(4)).
(2) Request appropriate medical records to evaluate the issues,
as necessary.
(3) Provide a complete report of the potential quality of care
issues to the Clinical Director (CD) and CHS Officer/Manager of
the service unit from which the patient was originally referred.
At the same time, copies shall be sent to the Chief Medical
Officer (CMO) and CHS Officer of the Area involved.
(4) Provide trend reports to each IHS Area and the CAG on at
least a semi-annual basis.
B. SERVICE UNIT CLINICAL DIRECTOR.
The CD of the service unit, upon receipt of the report from the FI,
shall notify the referring physician, if appropriate, and direct the
report to the service unit's quality improvement program. Within 4
weeks after receipt of the report from the FI, the CD shall provide a
written final or, if necessary, an interim disposition of the quality of
care issues to the Area CMO.
C. AREA CHIEF MEDICAL OFFICER.
Upon review of the service unit's determination, the Area CMO shall:
(1) Provide comments to the service unit as needed.
(2) Ensure that the provider in question is informed of the
quality of care issue, if appropriate.
(3) Take action in consultation with other appropriate offices
within IHS when deemed necessary to resolve the quality of care
issues.
(4) Inform the FI Medical Director of the disposition of the
issue and of any action required by the FI.
(5) Report the disposition of the issue to the CAG.
D. CLINICAL ADVISORY GROUP.
The CAG will generally serve as a resource and consultation group to
assist the Area CMO and Service Unit CD in making appropriate decisions.
The responsibilities of the CAG shall include but not be limited to:
(1) Recommending to the FI a series of indicators (sentinel
event screens for quality care) to be used in the FI's claims
editing and review process.
(2) Serving as a resource for the development and review of
quality of care edits.
(3) Reviewing reports of all quality of care issues and
dispositions at least twice a year.
(4) Reporting his/her findings and recommendations once each
fiscal year to the Area CMOs, Area CHS Officers, and the Managed
Care Committee. The findings of the CAG shall be used to:
a. Assist service units in making appropriate referrals of
patients to those providers who render services that meet IHS
standards of care.
b. Periodically revise the sentinel screens used by the FI.
c. Identify target areas for quality improvement.
6. REPORTING REQUIREMENTS.
A. The CAG shall provide annual reports to the Associate Director,
Office of Health Programs, and the Deputy Director, IHS, concerning
quality of care screens performed by the FI.
B. The CAG functions, the service unit and Area followups, and the
preparation and review of the annual report are an internal control
mechanism to address the Federal Managers Financial Integrity Act
requirements to assess risk, implement controls, and prevent fraud,
waste, and mismanagement.
7. EFFECTIVE DATE.
This circular is effective upon date of signature.
/s/MICHEL E. LINCOLN
Michel E. Lincoln
Acting Director
August 11, 1993
DISTRIBUTION: PSD 557 (Indian Health Service)
CIRCULAR NO. 93-4
IHS CIRCULARS
COSMETIC AND EXPERIMENTAL PROCEDURES REVIEW
Sec.
1. Purpose
2. Background
3. Definitions
4. Policy
5. Procedures
6. Reporting Requirements
1. PURPOSE. This circular outlines Indian Health Service (IHS)
policy regarding contract health services (CHS) referrals that are of a
potentially cosmetic or experimental nature. It describes the review
process for these requests by the Fiscal Intermediary (FI), Office of
Health Programs (OHP), and the Clinical Advisory Group (CAG).
2. BACKGROUND. When the amount of CHS funding is not adequate to
meet the total needs of the IHS service population, Federal regulations
require the IHS to limit CHS care through a system of established
medical priorities based on relative medical need.
The current IHS Medical Priorities List excludes authorization of
payment for purely cosmetic and experimental procedures. Occasionally,
a plastic surgery procedure specifically excluded by the IHS Medical
Priorities may be determined to be appropriate for CHS funding if it is
necessary for proper mechanical function or psychological reasons,
rather than being purely cosmetic in nature.
In addition, certain procedures which were previously judged
experimental may become acceptable under current practice standards.
For these reasons, it is necessary to implement a mechanism to review
CHS purchase delivery orders (PDOs) for procedures that are potentially
cosmetic or experimental in nature.
3. DEFINITIONS.
A. Fiscal Intermediary - an organization, under contract with the
IHS, that undertakes to validate and pay CHS claims.
B. Managed Care Committee - a committee, established by the
Director, to plan, develop, promote, and institute the principles of
managed care and ensure maximum access to quality health services
throughout the IHS.
C. Clinical Advisory Group - a group of four senior IHS physicians
appointed by the IHS to review medical care problems identified by the
FI and to act as an advisory group to the IHS on monitoring the quality
of medical care provided by the private sector that is paid by the FI.
4. POLICY. This policy applies to all IHS hospitals and clinics and
shall include the following:
The IHS Medical Priorities List shall include a description of
services excluded from coverage and will identify procedures that are
cosmetic or experimental in nature.
The FI and Area Chief Medical Officer (CMO) shall use established
mechanisms to review, prior to payment, all CHS requests for procedures
that are listed as cosmetic or experimental.
The CHS referrals for excluded or experimental procedures that are
listed in the IHS Medical Priorities will not be made, unless a formal
exception is granted by the Associate Director, OHP (IHS Chief Medical
Officer).
However, certain excluded or experimental cosmetic procedures that
are determined to be necessary for proper mechanical function or
psychological reasons shall be considered appropriate CHS referrals, and
approval shall be granted by the CMO.
5. PROCEDURES.
A. Cosmetic Procedures Review.
(1) Service Unit Review.
The service unit staff shall follow established procedures when
referring patients for CHS care.
When a service unit determines that a potentially cosmetic
procedure is absolutely required for a particular patient (because
of impaired mechanical function or psychological reasons), the
service unit will obtain pre-authorization approval from the CMO
and Area CHS Officer. Without such approval, the service will not
be paid by the FI.
(2) Chief Medical Officer and Area CHS Officer Review.
The CMO and Area CHS Officer will be responsible for evaluating
and approving requests for cosmetic procedures. The CMO
signature, or notation by the service unit of CMO approval, must
appear on the PDO document or in the designated computer field
(for electronic transfer of PDOs).
The CMO and Area CHS Officer will be responsible for the
evaluation of all claims for cosmetic procedures that are received
from the FI.
a. After evaluating the claim, the CMO will approve or
disapprove the claim and return the claim to the FI within 30
working days.
b. The FI will release the claim for payment if the CMO
approves payment.
c. Rejections.
If the CMO does not approve the claim, or if a response is not
received within 30 days of the referral to the CMO, the claim will
be rejected.
(i) The provider will be referred to the local IHS service unit
for payment of a PDO the FI is not authorized to pay.
(ii) The CMO and clinical director will be notified of all
claims rejected by this process.
(3) Fiscal Intermediary Review.
The FI will pend for review all claims for cosmetic procedures
prior to payment. The IHS Medical Priorities and the Health Care
Financing Administration (HCFA) Coverage Issuance Manual will be
used as a reference to determine which procedures are considered
cosmetic.
a. The FI staff will check the claim for CMO approval.
b. The claim will be released for payment if CMO approval is
noted on the PDO. Further FI review of these claims will occur
after the claim is paid.
c. Pending Claims.
When no CMO approval is noted on the claim, the claim will
remain pending during the entire review process.
(i) Medical records will be requested for all claims for
cosmetic procedures without CMO approval.
(ii) If a review of medical records supports that the procedure
is not purely cosmetic, payment will be made.
(iii) If a decision cannot be made to pay a pending claim based
on the medical records, the FI will refer the case to the CMO for
a determination.
(4) Cosmetic Procedure Reports.
a. All cases reviewed for cosmetic services will be logged in
the FI reporting system.
b. Semi-annual reports will be sent to each Area Office
detailing the findings of the review. The CMO can use this report
to ensure that procedures defined by the Area for authorization
and/or CMO approval of cosmetic procedures are being followed.
c. Trend reports will be extracted semi-annually from the
reporting system and referred to the CAG for review and comment.
The CAG will be responsible for annually reporting its findings
and recommendations to OHP, the CMOs, Area CHS Officers, and the
Managed Care Committee (MCC).
B. Experimental Procedures Review.
(1) Service Unit Review.
The service unit staff shall follow established procedures for
referring patients for CHS care. When the service unit staff
determines that the best treatment option for a patient requires a
procedure that is listed as experimental or excluded in the IHS
Medical Priorities and they have reason to believe that the
procedure in question is no longer considered experimental
(investigational), they will consult with the CMO prior to
authorizing the service.
(2) Chief Medical Officer Review.
The CMO will approve or disapprove the request. If the CMO
concurs with the service unit staff that the required procedure is
no longer considered to be experimental in nature, he/she will
consult with the Office of the Associate Director, OHP, to request
an exception to authorize payment for an excluded service.
(3) Office of Health Programs Review.
The OHP will respond to the request within 5 working days.
a. Exceptions must be based on valid and verifiable medical
reasoning.
b. The HCFA Coverage Issuance Manual and current medical
literature will be used as the basis for decision-making.
c. If approved, documentation of the approval from the
Associate Director, OHP, will be attached to the PDO.
d. On an annual basis, OHP will update the IHS Medical
Priorities to reflect changes in acceptable medical practice.
(4) Fiscal Intermediary Review.
All claims for potentially experimental procedures will be
pended by the FI for review prior to payment.
a. If OHP has issued an exception, then the claim will be paid.
b. All cases that are pending for experimental review that are
not cleared for payment by OHP will be forwarded to the FI Medical
Director to evaluate whether standard medical practice still
considers the procedure to be experimental.
(i) The CMO and service unit clinical director will be notified
of this action.
(ii) If the FI determines that standard medical practice has
changed, the FI Medical Director will refer the case to OHP for
consideration of a future revision of IHS Medical Priorities.
c. Rejections.
Claims for services rendered that are specifically excluded by
IHS Medical Priorities, and no written exception is received with
the PDO, will be rejected.
(i) The provider will be referred to the local IHS service unit
for payment of a PDO the FI is not authorized to pay.
(ii) The CMO, Area CHS Officer, and service unit clinical
director will be notified of all claims rejected by this process.
(5) Experimental Procedures Reports.
a. All cases reviewed for experimental services will be logged
in the FI reporting system.
b. Semi-annual reports will be sent to each Area Office
detailing the findings of the reviews.
c. Semi-annual reports will be submitted by the FI to the CAG
for review and comment. The CAG will be responsible for annually
reporting their findings and recommendations to OHP, the Area
CMOs, Area CHS Officers, and the MCC.
6. REPORTING REQUIREMENTS.
A. The CAG shall provide annual reports to the Associate Director,
OHP, and the Deputy Director, IHS, concerning cosmetic and experimental
procedure screens performed by the FI.
B. The CAG functions, service unit and Area followup, and the
preparation and review of the annual report are an internal control
mechanism to address the Federal Managers Financial Integrity Act
requirements to assess risk, implement controls, and prevent fraud,
waste, and mismanagement.
/s/MICHEL E. LINCOLN
Michel E. Lincoln
Acting Director
Indian Health Service
June 25, 1993
Distribution: PSD 557 (Indian Health Service)
CIRCULAR NO. 93-03
IHS CIRCULARS
CREDENTIALS AND PRIVILEGES REVIEW PROCESS FOR THE MEDICAL STAFF
Sec.
1. Purpose
2. Definitions
A. Medical Staff
B. Categories of Medical Staff
C. Verification
3. Background
4. Policy
A. Requirement for Credentials Review
B. Credentials Files
C. Required Elements for Review
D. Provisional Membership
E. Renewal of Membership
F. Clinical Privileges
G. Temporary Medical Staff
H. Responsibility for Reviews
5. Procedures
6. Supersession
Appendices
A. Procedures for Credentialing and Privileging the Medical
Staff
B. Suggested Forms for Credentials Review Process
C. Suggested Privileges Request Forms
1. PURPOSE. This Indian Health Service (IHS) Circular establishes
the elements of credentials review required for application or
reapplication for medical staff membership and/or clinical privileges at
IHS facilities. It is applicable to both hospital and ambulatory care
settings.
It does not address any additional elements that may be required for
employment or contract affiliations. Questions on these matters may be
directed to the Area Recruiters or Contracting Officers.
Recommended procedures and forms are appended to assist in the
effective and efficient implementation of this policy.
2. DEFINITIONS.
A. Medical Staff - The term "medical staff" shall include physicians
(M.D. and D.O.), dentists, and possibly other health care providers who
are licensed or otherwise permitted by a State and by the health care
facility to provide patient care services independently within the scope
of the profession and in accordance with individually granted clinical
privileges. The medical staff may include, therefore, psychologists,
optometrists, podiatrists, audiologists, certified nurse midwives,
certified registered nurse anesthetists, nurse practitioners, physician
assistants, and other health professionals, if they are licensed and
permitted by the facility to function as independent practitioners. The
composition of the local medical staff is left to the discretion of that
medical staff and its governing body. For all hospitals, the majority
of the Executive Committee of the Medical Staff shall be actively
practicing physicians.
B. Categories of Medical Staff - The following categories of the
medical staff are to be used as a guide but are not restrictive:
(1) Provisional-Those new members of the medical staff who are
serving a required probationary period as specified in the local
medical staff bylaws. During this time their qualifications for
membership on the active or courtesy medical staff are assessed.
In the IHS, depending on the local medical staff bylaws,
provisional active members may be permitted to vote at medical
staff meetings, whereas provisional courtesy members may not. The
staff member shall be deemed "Provisional-Active" or
"Provisional-Courtesy."
(2) Active-Those members who are either IHS employees or
employees of Public Law (P.L.) 93-638 tribal contractors who spend
a large proportion of their professional time within the IHS
facility and/or service unit. They have served their probationary
period and have been found to be fully qualified for membership on
the medical staff. Active staff members may vote at medical staff
meetings.
(3) Temporary-Those members who provide services on a
short-term basis or who have applied for active medical staff
membership but await a full credentials review. They are not
eligible to vote at medical staff meetings.
(4) Courtesy-Those members who generally provide or services on
a periodic or episodic basis Associate (e.g., hold specialty
clinics, provide laboratory consultation, serve as a radiologist)
and are frequently not IHS employees. An IHS Area consultant who
occasionally visits a service unit to see patients may join the
courtesy staff but is not eligible to vote at medical staff
meetings.
C. Verification - During the course of a credentials review, the
information obtained from an applicant shall be verified through the use
of letters, phone calls, or state licensing board computer printouts.
(Follow current Joint Commission Scoring Guidelines.) Primary source
verification is required of certain credentials, such as professional
education, post graduate training, and licensure. Secondary
verification, available through data banks such as the American Medical
Association Master File, may be helpful but must be considered
supplementary. All applicants will be checked against the National
Practitioner Data Bank (NPDB); the NPDB must be queried for all medical
staff at least every two years.
3. BACKGROUND. Health service delivery components of the IHS are
responsible for ensuring that their health care providers are qualified
and competent, and deliver quality health services consistent with those
of the medical community at large. This responsibility includes the
initial review and verification of a provider's credentials to determine
eligibility for medical staff membership and proper assignment. The
applicant's training, prior experience, and current competence are
considered as well as the needs of the medical staff relative to patient
load and diagnostic mix, and the ability of the facility to provide
adequate support facilities, services, and staff. This responsibility
also involves the delineation of facility specific privileges that each
provider is granted and requires a mechanism whereby the credentials and
privileges are re-evaluated and recertified on a regular basis.
The IHS policy requires facilities to meet the accreditation
standards of the Joint Commission on Accreditation of Healthcare
Organizations. Their current standards for accreditation include:
1. Providing for the possible expansion of medical staff
membership.
2. Establishing comprehensive policies and processes for the
credentialing and delineation of clinical privileges in order to:
a) Ensure the qualification and the current clinical competence
of health care staff.
b) Improve the quality and appropriateness of health care.
Within the IHS, the credentials review process and the granting
of clinical privileges evolved over the years to include a variety
of methods with some variation in the quality of review. While
content and procedural variations from Area to Area or service
unit to service unit may have reflected local needs, ingenuity, or
innovation, the variations presented an obstacle to the IHS in its
effort to assure itself, the Congress, local communities, and its
patients that IHS providers are qualified and meet acceptable
standards of practice.
For these reasons, the following policy was developed to
standardize the content of credentials review in the IHS and to
provide recommended procedures and sample forms which will assist
in complying with the policy. Local variations are possible so
long as the content and sequence adhere to the requirements set
forth in the following policy. Local variations of the privileges
request forms are encouraged, since only those privileges that can
be supported by the facility should be listed.
4. POLICY.
A. Requirement for Credentials Review - It is the policy of the IHS
that all individuals who are eligible for membership on the medical
staff or who provide direct, independent, and unsupervised patient care
services in IHS facilities or under IHS auspices must have a documented,
current review of their medical staff credentials. Before delivering
health care services to any patient, the applicant for medical staff
membership and/or clinical privileges must undergo a credentials review
as detailed below and be granted clinical privileges through the
procedures outlined in local medical staff bylaws. (Note special
arrangements for temporary medical staff who join the medical staff on
short notice.)
B. Credentials Files
(1) Storage and Maintenance
The medical staff credentials files are to be distinct from any
employment or contract files, representing instead the
professional relationship and responsibility aspects of the
members of the medical staff. Information in the credentials
files may, however, be derived from employment or contractual
files and data. These files are to be located in the service
unit; parts or all of this information may also be located in the
Area Office.
(2) Access, Safeguards, and Retention Access to these files is
limited to authorized personnel for use in the performance of
their official duties. The Area Director and Clinical Director of
each facility are designated as System Managers. He/she will
develop and maintain a list of personnel who are authorized access
and a log of any disclosures of information from these files.
These records are confidential and therefore must be secured at
all times. They must be retained at least five years after an
individual's termination from the medical staff. Records of
unsuccessful applicants for medical staff membership will be
retained for three years. When disposed of, they are to be
destroyed by shredding or burning.
(3) Privacy Act Considerations These records are to be
maintained in the IHS system of records 09-17-0003, published in
the Federal Register, November 22, 1988, pages 47355-47358. This
notice contains the following information which describes this
system of records:
a. The name and location of the system;
b. The categories of individuals on whom records are maintained
in the system;
c. The categories of records maintained in the system;
d. Each routine use of the records contained in the system
including the categories of users and the purpose of such use;
e. The policies and practices of the IHS regarding storage,
retrievability, access controls, retention, and disposal of
records;
f. The title and business address of the IHS official who is
responsible for the system of records;
g. The IHS procedures whereby individuals can be notified at
their request, if the system of records contains a record
pertaining to them;
h. The IHS procedures whereby individuals can be notified at
their request how they can get access to any record pertaining to
them contained in the system of records, and how they can contest
its content;
i. The categories of sources of records in the system.
C. Required Elements for Review - The credentials review must, at a
minimum, address the following areas, noting the special considerations
in each. All information requires verification:
(1) Professional Education
All medical staff members, and those practitioners who fall
under the aegis of the medical staff, must possess a diploma as a
graduate of a professional school accredited by a
nationally-recognized accrediting body, appropriate for the
member's professional discipline. The foreign graduate must
possess a diploma as a graduate of a professional school and
documentation of having successfully completed appropriate
certifying requirements, e.g., ECFMG and/or FLEX for physicians,
as applicable to the specific profession.
(2) Post-Graduate Training
a. All physicians and other medical staff whose professional
disciplines require post-graduate clinical training must possess
certification of such training in a program accredited by a
nationally-recognized accrediting body.
b. Any internships, residencies, fellowships, or other
organized professional training which has been completed should be
specified, including dates of participation, location, type of
program, and name of program director.
(3) Experience
The elapsed time since graduation from professional school
should be accounted for, with a summary of jobs or medical staff
memberships, locations, dates, and types of activities or
privileges.
(4) Professional Affiliations
Any board certification held by an applicant and any
professional association to which an applicant belongs should be
noted.
(5) Licensure
All members of the medical staff must hold an active and
unrestricted state license, certification, or registration, as
applicable, to practice independently in their professional field.
(6) Suitability for membership and/or granting clinical
privileges
a. All applicants requesting initial appointment to the medical
staff and/or clinical privileges must furnish information
pertaining to the following (See pp. 1, 5-6 of the "Application
for Appointment to the Medical Staff"):
(i) Professional liability claims and judgments made against
them
(ii) Previous denial or revocation of medical staff membership
at another facility
(iii) Previous reduction, suspension, revocation, voluntary
relinquishment, or non-renewal of privileges at another facility
(iv) Problems with alcohol or drug abuse.
(v) Previous loss, suspension, restriction, denial, or
voluntary relinquishment of professional licensure or professional
society membership
b. Unfavorable information pertaining to suitability must be
provided to the Area Office Personnel Security Adjudicator.
c. All applicants for reappointment must have similar
suitability criteria reviewed as well.
(7) References
All applicants for initial membership and/or clinical
privileges must provide three letters of reference from persons
who can attest to the applicant's professional judgment,
competence, and character. One letter must be from the training
program for those applicants just completing professional school
or post graduate clinical training. For other applicants, who are
currently members of one or more medical staffs, one letter must
be from the chief of staff or departmental chairperson from each
hospital where the applicant is on the active medical staff.
(8) Health Status
All applicants, both for initial appointment and reappointment,
must be physically and mentally capable of carrying out the
required functions of their medical staff role and the privileges
they are requesting.
(9) Attestations and Release
Each applicant for initial appointment must sign a "Statement
of Understanding and Release" form such as the one included in
Appendix B.
D. Provisional Membership - All medical staff members must complete
a required provisional membership period as specified in the medical
staff bylaws. Progression from provisional member to active member
requires an evaluation of professional judgment, competence, and
character, as well as evidence of satisfactory participation in the
functions of the medical staff as detailed in the medical staff bylaws.
E. Renewal of Membership - Medical staff membership must be limited
to no more than two years before a member's credentials are reassessed
for consideration of renewal. Renewal is not automatic nor guaranteed.
F. Clinical Privileges - Clinical privileges are granted after
careful review and consideration of an applicant's credentials. This is
done at the time of initial application or reapplication and at any time
that modification of privileges is indicated or requested.
No practitioner can hold unlimited privileges. The granting of
privileges must reflect the training, experience, and qualifications of
the applicant as they relate to the staffing, facilities, and
capabilities of the service unit. Recommendation of privileges should
be made by the Executive Committee of the Medical Staff (or its
equivalent as defined in the medical staff bylaws) to the chairman of
the governing body. This recommendation should be routed through the
Clinical Director and Service Unit Director to the service unit
governing body. Clinical privileges are granted after consultation with
discipline-specific staff or consultants, as appropriate.
G. Temporary Medical Staff - Applicants for temporary medical staff
membership and/or clinical privileges are subject to the same review as
other members, with the following exception. Insufficient time may
preclude carrying out a full credentials review before the temporary
staff applicant begins to provide patient care services. They may
provide services prior to a complete review as long as the following has
occurred: an application form has been completed; privileges have been
requested; both have been reviewed by the Clinical Director (or medical
staff officer in charge) and found to be in apparent conformance with
IHS standards; and the Service Unit Director has granted temporary
privileges until the governing board takes action. The usual
credentials review and approval must then be completed as soon as
possible.
H. Responsibility for Reviews - The Clinical Director at each IHS
facility is responsible for ensuring that the credentials review process
is carried out for every member of the medical staff. He/she may
delegate the authority (but not the responsibility) for carrying out the
review, or parts of the review, to other members of the medical staff,
to administrative personnel at the service unit, or to administrative or
clinical personnel in the Area Office.
5. PROCEDURES. The appendices to this Circular provide specific
guidance and sample forms to assist in the review of credentials for
purposes of granting medical staff membership and/or clinical
privileges. These procedures and forms are not required, but they do
meet the requirements of this policy. Area or service unit variations
in either the process or the forms used in credentials review should be
assessed to ensure compliance with the policy and with Joint Commission
accreditation requirements. The clinical privileges request forms are
to be tailored to the facility, since the facility must have the
capacity to support a clinical privilege that is granted. Privileges
that cannot be supported should not be included in privileges request
forms. If the appended procedures and forms are used in conjunction
with the requirements of the hiring process, a very complete and
valuable credentials review can be carried out.
6. SUPERSESSION This circular supersedes IHS Circular No. 89-7
Credentials and Privileges Review Process for the Medical Staff dated
September 8, 1989.
/s/MICHEL E. LINCOLN
Michel E. Lincoln
Acting Director
Indian Health Service
June 24, 1993
ATTACHMENT
Procedures for Credentialing and Privileging the Medical Staff
The medical staff of an IHS facility may be comprised of physicians,
dentists, optometrists, psychologists, audiologists, podiatrists,
certified nurse midwives, certified registered nurse anesthetists, nurse
practitioners, physician assistants, and other health professionals, if
licensed, and permitted by the facility, to function as independent
practitioners. They must provide direct patient care in that facility
but need not be employed by the IHS. The composition of the local
medical staff is left to the discretion of that medical staff and its
governing body. All persons in these professions who wish to practice
at an IHS facility must apply for clinical privileges. The Executive
Committee of the Medical Staff must review these applications and
recommend to the governing body whether the applicants should be granted
or denied membership, if applicable, and which specific clinical
privileges should be granted. The Service Unit Director also reviews
the applications and recommends acceptance/rejection of membership
and/or granting/denial of privileges to the governing body. The service
unit governing body will accept or reject the application for medical
staff membership and/or grant or deny the requested privileges.
The credentialing and privileging processes are separate and distinct
from the employment process, although it is important that all of these
efforts are coordinated. Much of the information obtained during
application for employment applies to credentialing and can be used to
augment the credentialing efforts. It is important that unfavorable
information pertaining to suitability be provided to the Area Office
Personnel Security Adjudicator prior to employment, if it is known at
that time.
Credentialing and privileging must be completed before a medical
staff member's entry on duty, then at intervals established in the
medical staff's bylaws, rules, and regulations. In no case can this
interval exceed two years.
When the applicant for membership or privileges is the Clinical
Director of the facility, the Chief of Staff (if such a distinction is
made), Assistant Clinical Director, and/or Area Chief Medical Officer
must be actively involved in the credentials review process. They must
address all functions in the review process that would normally be
handled by the Clinical Director.
The following steps should be completed in the specified
credentialing and privileging processes:
Initial Credentialing and Privileging
When an independent health care practitioner indicates a desire to
join the medical staff and/or obtain clinical privileges at an IHS
facility, the following should occur:
1. The Area or service unit considering the person sends the person a
packet containing the medical staff and clinical privileges
applications.
2. When the applications have been returned, an appropriate person
(Area physician recruiter, Area discipline-specific consultant, quality
assurance staff, Clinical Director or designee, etc.) reviews them for
completeness, then:
a. Verifies licensure with the appropriate State body;
b. Verifies level of training with school, internship or
residency program;
c. Speaks with references to verify clinical competence,
ability to get along with people, physical and mental health
status, liability history (malpractice suits or claims filed,
whether and how settled) etc.;
d. Provides the findings of this initial verification and
review to the Clinical Director of the IHS facility considering
the applicant for staff membership, certifying the accuracy and
authenticity of the information provided.
3. The Clinical Director reviews the applications for the following:
a. Completeness;
b. Appropriateness to the facility (including whether the
applicant has requested privileges which the facility cannot
support and whether he/she has not requested privileges which the
facility requires);
c. Accuracy of statements made on applications in comparison
to information obtained from references and other sources.
4. The Clinical Director reviews the applications and additional
information with the credentials committee, if applicable, and with the
Medical Staff Executive Committee, which recommends that the
applications to the staff be accepted or rejected and which of the
requested clinical privileges should be granted. Finally, the Clinical
Director forwards the Executive Committee's recommendations to the
Service Unit Director.
5. The Service Unit Director reviews the applications and the
Medical Staff Executive Committee's recommendations, satisfies
himself/herself of the appropriateness of the Committees's
recommendations, and sends his/her recommendations to the governing
body.
6. The service unit governing body, with input from the
discipline-specific consultant, if applicable, reviews the applications
and grants or denies the staff membership and/or clinical privileges to
the applicant, and then informs the Medical Staff Executive Committee
and the applicant of their decision in writing.
Medical Staff Membership and Privileges Renewal
At intervals specified in the medical staff's bylaws, rules, and
regulations, but in no case to exceed two years, all medical staff must
renew their medical staff membership and/or clinical privileges. This
process will normally be completed by the Clinical Director or his/her
designee and includes the following steps:
1. The staff member provides to the Clinical Director:
a. Applications to renew his/her membership and clinical
privileges, indicating any desired changes in clinical privileges.
b. Verification of current licensure.
c. Evidence of continuing professional education obtained
outside the facility.
2. The Clinical Director (or designee) ensures the performance and
documentation of the following tasks:
a. Review the application for completeness.
b. Review the person's service unit file to determine his/her:
1) Competency of practice (should be obtainable from records of
performance appraisals, Quality Assurance Committee, various other
medical staff and hospital committees, peer recommendations, as
well as anecdotal information known to the Clinical Director and
available from other medical staff members).
2) Participation in continuing education activities.
3) Participation in medical staff activities.
4) Ability and desire to get along with other staff members
(medical and support).
5) Current physical and mental health status.
Consider: Have there been any instances of behavior that
required disciplinary action or medical or psychiatric
intervention since the last time privileges were granted? Have
those situations been satisfactorily resolved? Are these still
issues of concern? Are any problems with alcohol or drug abuse
evident?
c. Review the applications and his/her findings with the
Medical Staff Executive Committee to arrive at a recommendation
concerning renewal of staff membership and clinical privileges,
with special attention to any requested or recommended changes in
clinical privileges. The applicant whose renewal is being
considered by the Medical Staff Executive Committee shall not be
present during this review.
d. Forward the Committee's recommendations to the Service Unit
Director.
3. The Service Unit Director reviews the applications and
recommendations, then forwards them to the service unit governing body.
4. The service unit governing body, with input from the
discipline-specific consultant, if applicable, reviews the applications
and grants or denies the staff membership and/or clinical privileges to
the applicant, and then informs the Medical Staff Executive Committee
and the applicant of their decision in writing.
5. The Clinical Director reviews the governing body's decision with
the staff member.
Note: If an applicant disagrees with the the outcome of the
foregoing process, the appeals and fair hearing procedures are to be
followed to resolve the disagreement. These procedures should be
addressed in every service unit's medical staff bylaws.
Credentialing and Privileging Temporary Medical Staff Members
All temporary members of the medical staff must be subjected to the
same credentialing and privileging process as members of the other
medical staff categories. In most instances, it should be possible to
complete the process before the person reports for duty. Occasionally,
however, there may be an emergency situation where there is not enough
time to get the applications to the person before he/she leaves for the
service unit. In these instances, the temporary staff member should:
1. Bring a copy of his/her license to the service unit.
2. Bring a copy of his/her notice of board certification,
completion of internship or residency, or other verification of
certification or training, as applicable.
3. Bring copies of at least three letters of recommendation.
4. Complete the applications for medical staff membership and
clinical privileges immediately upon reporting to the service
unit.
5. Bring evidence of medical liability insurance (contract
providers only).
When he/she learns that there will be an emergency need for a
temporary medical staff member, the Clinical Director should notify the
Area Physician Recruiter, Chief Medical Officer, or discipline-specific
consultant as to who the replacement is, when he/she is arriving, and
how long he/she will be there.
When the staff member arrives, the Clinical Director should:
1. Ensure that the staff and privileges application forms are
completed.
2. Review the materials (license, etc.) brought by the
temporary medical staff applicant to ensure that they are in order
and that the individual has adequate training, experience,
competence, and skills appropriate for the needs of the particular
facility. If letters of recommendation are unavailable,
references must be checked via telephone.
3. Begin the credentialing process described earlier in this
issuance. The Clinical Director will make recommendations to the
service unit Director who can grant temporary privileges until the
governing body can convene. These steps must be completed prior
to permitting the individual to see patients and provide care in
the facility.
When these steps have been completed, the remainder of the process is
the same as for all other staff members.
Suggested Forms For Credentials Review Process
Appendix B consists of the following:
1. Application for Appointment to the Medical Staff
2. Verification of Application for Appointment to the Medical Staff
and Evaluation of Request for Clinical Privileges
3. Suggested Format for Letter to be Sent to References of
Applicants or for Telephone Solicitation of References
4. Request for Reappointment to the Medical Staff
5. Work Sheet for Reappointment to the Medical Staff
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 45 minutes. This estimate may vary from a low of 30 minutes to a
high of one hour per response. This burden time estimate includes time
for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding the burden estimate
or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H.
Humphrey Building, Room 721-B, 200 Independence Avenue, SW, Washington,
D.C. 20201; and to the Paperwork Reduction Project, (0917-0009),
Office of Management and Budget, Washington, D.C. 20503. DO NOT SEND
COMPLETED FORMS TO EITHER OF THESE TWO ADDRESSES.
PLEASE TYPE OR PRINT LEGIBLY
INDIAN HEALTH SERVICE
APPLICATION FOR APPOINTMENT TO
THE MEDICAL STAFF OF
PHS Indian______________________ ,________________________ ,________
(Hospital/Health Center) Town State
as a Physician____; Dentist____; Psychologist____;
Optometrist____; Audiologist____; Podiatrist____;
Other________________________.
I. DEMOGRAPHIC INFORMATION
A. Name in Full:
B. Office Address:
Telephone:
C. Home Address:
Telephone:
D. Date of Birth: ________________________ Birthplace:
____________
Citizenship
II. HEALTH STATUS (Applicant is required to provide evidence of a
complete physical exam within one year prior to application).
A. Please note any significant physical or mental conditions,
present or past drug or alcohol abuse or dependency, or chronic
contagious diseases.
B. Last Medical Exam: Date____________Location__________________
C. Examiner: Name_____________________________________
Address ________________________________________________
D. Immunity Status:
Disease__________Date of Vaccination/Titer______Titer Result______
Rubella
Rubeola
E. Tuberculosis Status:
Date of last PPD:
Result: Pos Neg If positive, explain.
III. PRE-PROFESSIONAL EDUCATION: If more than two schools, give
information on an attached sheet.
College/University:
Address:
Dates Attended:
Date of Graduation:
Degree:
Honors:
College/University:
Address:
Dates Attended:
Date of Graduation:
Degree:
Honors:
IV. PROFESSIONAL EDUCATION: If more than one school, identify and
explain on separate sheet.
College/University:
Address:
Dates Attended:
Date of Graduation:
Degree:
Honors:
V. INTERNSHIP: (or other single post-graduate year)
Hospital/Location:
Address:
Type/Specialty:
Dates:
VI. RESIDENCIES: Fellowships, Preceptorships, Post-graduate
Education, Teaching Appointments (most recent first)
A. Hospital/Location:
Address:
Type/Specialty:
Dates:
B. Hospital/Location:
Address:
Type/Specialty:
Dates:
C. Hospital/Location:
Address:
Type/Specialty:
Dates:
VII. SPECIALTY BOARDS:
CERTIFIED DATE RECERTIFIED DATE
A.________________________ _________ ____ ___________ ____
B.________________________ _________ ____ ___________ ____
VIII. PROFESSIONAL LICENSURE (certification, registration) (List all
jurisdictions in which you currently hold or have ever held a
professional license; continue on a separate sheet if more than three):
STATE NUMBER EXPIRATION DATE
A. ______________________ ______ _______________
B. ______________________ ______ _______________
C. ______________________ ______ _______________
IX. Drug Enforcement Administration (DEA) Number.______________
X. AFFILIATIONS: List present and previous clinical practice
affiliations.
A. INDIVIDUAL/GROUP:
1. Name:_______________________ Dates:______________________
Address:_____________________________________________________
Nature/Position:_____________________________________________
2. Name:_______________________ Dates:______________________
Address:_____________________________________________________
Nature/Position:_____________________________________________
B. HOSPITAL/MEDICAL STAFF: Include military or other Federal or
State Government services.
1. Name:_______________________ Dates:______________________
Address:_____________________________________________________
Position/Title:______________________________________________
2. Name:_______________________ Dates:______________________
Address:_____________________________________________________
Position/Title:______________________________________________
3. Name:_______________________ Dates:______________________
Address:_____________________________________________________
Position/Title:______________________________________________
XI. MEMBERSHIP IN PROFESSIONAL SOCIETIES:
A.___________________________________________________________
B.___________________________________________________________
C.___________________________________________________________
D.___________________________________________________________
XII. PROFESSIONAL REFERENCES: The names, mailing addresses, and
telephone numbers of at least three (3) individuals are required.
A.___________________________________________________________
_____________________________________________________________
_____________________________________________________________
B.___________________________________________________________
_____________________________________________________________
_____________________________________________________________
C.___________________________________________________________
_____________________________________________________________
_____________________________________________________________
Note: Written information from 3 references is required before
action can be taken on this application. For those in training, one
reference must be from the Director (Chief of Service) of the training
program. For other applicants, who are currently members of one or more
medical staffs, one letter must be from the Chief of Staff or
Departmental Chairperson from each hospital where the applicant is on
the active medical staff. Information will be requested regarding
professional judgment, competence, and personal character. References
will be evaluated based on the extent of direct work with and clinical
observation of the applicant.
XIII. CONTINUING PROFESSIONAL EDUCATION: Describe topics, sources,
and dates of all continuing education you have completed in the last 3
years and professional recognition certificate received, if applicable
(summary sheet may be attached).
XIV. CPR TRAINING:
Current training and certification in cardiopulmonary resuscitation
(CPR), basic life support, is highly desirable for all professionals
involved in direct patient care. The CPR training will be required of
some in accordance with medical staff bylaws, particularly of
physicians, dentists, and optometrists.
A. I have had no CPR Training within the past year.
B. Certified in basic life support?
Certification expires on_______________________
C. Certified in advanced cardiac life support?
Certification expires on_______________________
D. Certified in advanced trauma life support?
Certification expires on_______________________
E. Certified in pediatric advanced life support?
Certification expires on_______________________
XV. LIABILITY INSURANCE: (List current carrier first and any other
carriers for the past 10 years - continue on a separate sheet if
necessary)
A. Carrier:_____________________ Amount of coverage:________________
Agent:__________________________ Policy No.:________________________
Expiration Date:________________________________
B. Carrier:_____________________ Amount of coverage:________________
Agent:__________________________ Policy No.:________________________
Dates:__________________________________________
C. Carrier:_____________________ Amount of coverage:________________
Agent:__________________________ Policy No.:________________________
Dates:__________________________________________
XVI. Liability Claims and Adverse Action
If your answer to any of the following is "yes," please provide full
details on an attached separate sheet:
A. Have liability claims been filed against you, or against a
hospital, other health care entity, corporation, or government, based on
a case under your care? YES:_____ NO:_____
B. Have judgments or settlements been made involving you or against a
hospital, corporation, or government based on a case under your care?
YES:_____ NO:_____
C. Have you ever had, or are you about to have, your professional
liability insurance declined, canceled, issued on special terms, or
refused for renewal? YES:_____ NO:_____
D. Has your professional license (certification or registration) to
practice in any jurisdiction ever been limited, placed in probationary
status, restricted, suspended, denied, revoked, voluntarily surrendered,
or not renewed? YES:_____ NO:_____
E. Have you ever been censured or reprimanded by a licensing
(certifying, etc.) board, hospital medical staff, professional society,
or other professional organization? YES:_____ NO:_____
F. Have you ever been refused membership on a medical, dental, or
other professional staff? YES:_____ NO:_____
G. Have any or all of your privileges at any health-care facility
ever been or are about to be limited, reduced, suspended, revoked,
voluntarily surrendered in the course of an investigation, or not
renewed? Have you resigned from a medical staff because of concern that
your privileges might have been limited, suspended, or revoked? Have
any other professional disciplinary actions been taken against you?
YES:_____ NO:_____
H. Has your narcotics registration, Federal or State, ever been
denied, limited, suspended, voluntarily surrendered, not renewed, or
revoked? YES:_____ NO:_____
I. Have you ever been denied membership, or renewal thereof, or been
subject to disciplinary action in any professional society or
organization? YES:_____ NO:_____
J. Have any civil or criminal charges ever been filed against you, or
are you under an investigation that might lead to such charges?
YES:_____ NO:_____
K. Have you ever been sanctioned by Medicare or a Medicaid program or
by any other Federal agency? YES:_____ NO:_____
L. Are you currently involved in or have knowledge of a pending
investigation, review, or surveillance of your professional practice or
conduct that could result in an adverse action concerning your narcotics
registration; ability to bill and collect from Medicare or Medicaid
programs; professional license, registration, or certification; or
medical staff membership or privileges? YES:_____ NO:_____
Explain affirmative responses in detail.
I agree to abide by all lawful standards, policies, and rules of the
facility, the Area, the Indian Health Service, the U.S. Public Health
Service, and the Department of Health and Human Services as they apply
to my responsibilities and practice as a member of this medical staff.
I pledge to maintain an ethical practice and to provide for the
continuous care of all my patients. I further agree to immediately
disclose to the medical staff and/or governing body more detailed
information related to all "yes" responses in Section XVI of this
application, if asked to do so. In addition, I agree to immediately
report to the Clinical Director any new information concerning a "yes"
response or concerning a response that becomes "yes" after filling out
this medical staff application, either while medical staff membership
and/or privileges are pending or after they have been granted.
Applicant's Signature____________________ Date________________
RECOMMENDATIONS AND APPROVALS
1. DISCIPLINE-SPECIFIC SUPERVISOR OR CONSULTANT (if a current member
of the medical staff)
I do____; do not____ recommend appointment to the medical staff.
Comments:
Signature____________________________ Date_____________________
2. EXECUTIVE (or Credentials & Privileges) Committee
We do____; do not____ recommend appointment to the
provisional____
active____
temporary____
courtesy____ medical staff.
Comments:
Signature ________________________ Date______________________
3. CLINICAL DIRECTOR
I do____; do not____ recommend appointment to the
provisional____
active____
temporary____
courtesy____ medical staff.
Comments:
Signature_________________________ Date________________________
4. SERVICE UNIT DIRECTOR
I do____; do not____ recommend appointment as noted above.
Comments:
Signature_________________________________ Date________________
5. CHAIR, SERVICE UNIT GOVERNING BODY
Appointment is_______; is not_______ approved.
Comments:
Signature_________________________________ Date_________________
STATEMENT OF UNDERSTANDING AND RELEASE
(To be signed by all applicants, for initial appointment)
By applying for appointment to the medical staff, I signify my
willingness to appear for interviews in regard to my application and
authorize IHS representatives to consult with administrators and members
of medical staffs of other institutions with which I have been
associated and with others (including past and present insurance
carriers, State licensure boards, etc.) who may have information bearing
on my professional competence, character and ethical qualifications. I
further consent to the release/disclosure to this facility's
professional staff and IHS representatives of all personnel,
professional, and personal medical records and documents (including
alcohol and drug abuse records at other institutions) that may be
material to an evaluation of my professional qualifications and
competence to carry out the clinical privileges requested, as well as my
moral and ethical qualifications for staff membership.
I further consent to the disclosure, by authorized IHS
representatives, of records of my professional service with IHS relating
to my personal character and professional qualifications and competence
to carry out the clinical privileges granted to me by this IHS facility.
This information may be disclosed to any subsequent practitioner(s),
facility, State or county medical society, or licensing board to whom or
to which I may apply for clinical privileges, membership, or licensure.
This may include information regarding drug or alcohol abuse or
dependency. At such time, completion of the form titled:
"Authorization for Release of Information," Form No. HRSA-810, will be
requested.
I fully understand that a false answer to any question in this
application, or the misrepresentation of information otherwise provided,
may constitute cause for denial/revocation of medical staff appointment
and/or clinical privileges, and may be punishable by fine or
imprisonment (U.S. Code, Title 18, Section 1001).
I certify that the statements/documents that I have made/provided in
this application are true, complete, and correct to the best of my
knowledge and belief and are made in good faith.
I hereby release from liability all representatives of the Federal
Government for their acts performed in good faith and without malice in
connection with evaluating my credentials and qualifications, and I
hereby release from any liability any and all individuals and
organizations who provide information to these representatives in good
faith and without malice concerning my professional competence, ethics,
character, and other qualifications for the medical staff and any
applicable clinical privileges.
I agree to abide by the bylaws, rules, and regulations of the medical
staff.
DATE_____________ SIGNATURE___________________
PRIVACY ACT NOTICE FOR CREDENTIALS AND PRIVILEGES REVIEW PROCESS FOR
THE MEDICAL STAFF
(Notice to subject individual)
The Privacy Act of 1974 (5 U.S.C. 552a) requires that a Federal
agency provide a notice to each individual from whom it collects
information.
1. The authority for collecting the information requested is found in
the Indian Self Determination and Education Assistance Act (25 U.S.C.
450), Snyder Act (25 U.S.C. 13), the Indian Health Care Improvement Act
(25 U.S.C. 1601 et. seq.), and the Transfer Act (42 U.S.C. 2001-2004).
2. The principal purpose for collecting the requested information is
to systematically review the credentials of all current members of IHS
medical staffs and those of persons applying for positions on IHS
medical staffs, either as employees or contractors, regarding membership
and the granting of clinical privileges.
This information is being requested to ensure that members of
the IHS medical staff are qualified, competent, and capable of
delivering quality health services consistent with those of the
medical community at large and that they are granted privileges
commensurate with their training and competence and with the
ability of the facility to provide adequate support equipment,
services, and staff. This responsibility includes the initial
review and verification of a provider's credentials for the
purposes of determining eligibility for medical staff membership.
The applicant's training, prior experience, and current
competence, the needs of the IHS medical staff relative to patient
load and diagnostic caseload mix, and the ability of the facility
to provide adequate support facilities, services, and staff must
be considered prior to granting medical staff membership and
delineating specific medical staff privileges. This
responsibility requires a mechanism whereby the credentials and
clinical privileges will be evaluated, re-evaluated, and
recertified on a recurring and standardized basis.
3. Information contained in the records created for these purposes
will be maintained by IHS staff in a confidential manner. Releases of
this information will only be made on a "need-to-know" basis to
employees of the Department of Health and Human Services in the
performance of their official duties and to non-Departmental personnel
for the following routine uses: Records, in part or total, may be
disclosed to:
(a) Authorized organizations to conduct program evaluation
studies sponsored by IHS (e.g., Joint Commission on Accreditation
of Healthcare Organizations).
(b) State or local government health profession licensing
boards, the National Practitioner Data Bank established under
Title IV of P.L. 99-660, the Federation of State Medical Boards
and/or similar entities to inform them of current or former IHS
medical staff members whose professional health care activity so
significantly failed to conform to generally accepted standards of
professional medical practice as to raise reasonable concern for
the health and safety of members of the general public. This will
be done within the guidelines for notice, hearing, and appellate
review as delineated in the medical staff bylaws for the IHS
facility and/or within other HHS or IHS regulations or policies.
(c) References listed on the IHS medical staff application and
associated forms for the purpose of evaluating your professional
qualifications, experience, and suitability.
(d) State or local health professional licensing boards, health
professional organizations, the data bank established under Title
IV of P.L. 99-660, the Federation of State Medical Boards or
similar entities for the purpose of verifying that all claimed
background and employment data are valid and all claimed
credentials are current and in good standing.
(e) Other agencies of the Federal, State, and local governments
as well as organizations in the private sector that you have
applied to or will apply to for clinical privileges, membership or
licensure for the purpose of documenting your qualifications and
competency to provide health services in your health profession
based on your professional performance while employed by the IHS.
(f) Department of Justice in case of litigation.
(g) Federal, State, or local agency charged with enforcing or
implementing a statute, rule, regulation, or order when
information contained in the record indicates a violation or
potential violation of law, whether civil, criminal, or regulatory
in nature.
4. Indian Health Service staff will maintain a log of such
disclosures. You may review a copy of this log of disclosures or review
copies of materials contained in your medical staff credentials and
privileges file. To do so, contact the Clinical Director of your
facility or the Area Director, if the official file is maintained at the
Area Office.
5. Information collected through the use of Indian Health Service
Credentials and Privileges Review forms are contained in System of
Records: 09-17-0003, Indian Health Service Medical Staff Credentials
and Privileges Records, HHS/IHS/OHP.
6. Applicants are advised that failure to provide the information
requested, including Social Security Number, will result in a denial to
receive, or to continue to receive, funding as an IHS medical staff
member (direct or contract).
TO BE COMPLETED BY CLINICAL DIRECTOR OR DESIGNEE
INDIAN HEALTH SERVICE
VERIFICATION OF APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF AND
EVALUATION OF REQUEST FOR CLINICAL PRIVILEGES
This form is provided to facilitate the process of validation of
credentialing information provided by applicants in the Application for
Appointment to the Medical Staff, to provide a concise record of the
steps taken, and to verify the completion of all steps in the validation
process. Use of this form is not required; however, CLINICAL DIRECTOR
MUST SIGN CERTIFICATION TO INDICATE THAT INFORMATION PROVIDED BY
APPLICANT HAS BEEN VALIDATED.
(Numbers noted in parenthesis reference the item numbers on the
Application for Appointment to the Medical Staff form, Appendix B.1)
APPLICATION INFORMATION VERIFIED BY DATE
(ITEM NO.) DESCRIPTION (INITIALS) VERIFIED
1. (IV) Professional Education
2. (V) Internship
3. (VI) Residencies
Facility(ies) contacted
Comments:
4. (VII) Boards
Indicate how validated:
Comments:
5. (VIII) Licensure(s)
State How Validated
A.
B.
C.
Comments: (note any limitations or restrictions)
6. National Practitioner Data Bank query
Comments:
7. (X) Affiliations
A. Individual/Group
1) Name:
Comments:
2) Name:
Comments:
B. Hospital/Medical Staff
1) Name:
Position/title confirmed? YES NO
Privileges ever modified or reduced? YES NO
Disciplinary action? YES NO
Adverse actions? YES NO
Comments:
2) Name:
Position/title confirmed? YES NO
Privileges ever modified or reduced? YES NO
Disciplinary action? YES NO
Adverse actions? YES NO
Comments:
3) Name:
Position/title confirmed? YES NO
Privileges ever modified or reduced? YES NO
Disciplinary action? YES NO
Adverse actions? YES NO
Comments:
8. (XII) Written References (3) On File
A.
B.
C.
Note any negative comments:
9. (XV) Liability Insurance
Insurance in force? YES NO
Carrier:
Coverage:
10. (XVI) Comments regarding validation of all "yes" answers
concerning liability claims and adverse action:
11. Privileges requested are consistent with
training and experience confirmed in the
verification process.
12. Monitoring/Supervision is recommended. YES NO
If yes, indicate:
Type:
Duration:
By Whom:
Comment:
13. Information presented to Executive Committee of the
Medical Staff
Comments of Executive Committee of the Medical Staff:
14. Recommendation of Executive Committee of the Medical Staff:
A. Membership with privileges as requested.
B. Membership with privileges modified as noted.
C. Non membership (state reason)
CERTIFICATION
I certify that the information provided by the applicant has been
validated and, to the best of my knowledge, is correct.
_____________________Date___________________________Clinical Director
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 10 minutes. This estimate may vary from a low of 5 minutes to a high
of 20 minutes per response. This burden time estimate includes time for
reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding the burden estimate or any
other aspect of this collection of information including suggestions for
reducing this burden to Reports Clearance Officer, Attention: PRA,
United States Public Health Service, Hubert H. Humphrey Building, Room
721-B, 200 Independence Avenue, SW, Washington, D.C. 20201; and to the
Paperwork Reduction Project, (0917-0009), Office of Management and
Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED FORMS TO EITHER
OF THESE TWO ADDRESSES.
SUGGESTED FORMAT FOR LETTER TO BE SENT TO REFERENCES OF
APPLICANTS OR FOR TELEPHONE SOLICITATION OF REFERENCES
Name Date
Address
Dear Dr./Mr./Ms.__________________________:
Dr./Mr./Ms.______________________has applied for membership to the
medical staff of the Indian Health Service hospital/clinic in_________(
location). We are in the process of validating information contained in
his/her application and are asking that you provide us with your
assessment of Dr./Mr./Ms.________________in regards to his/her
professional judgment, competence, and personal character. Also, please
note the extent to which you have worked with the applicant and/or
observed his/her clinical performance. A check sheet has been enclosed
with this letter to facilitate your evaluation. Some or all of the
information you give us could in the future be released to a State
licensing board or similar entity, to other agencies of the Federal
Government, or for legal purposes. Your response is voluntary;
however, we hope that you will provide this information to us so that we
can process Dr./Mr./Ms.__________________'s application with the most
accurate information possible.
Sincerely,
Clinical Director
IHS MEDICAL STAFF PROFESSIONAL REFERENCE CHECKLIST
APPLICANT'S NAME:____________________________ DATE:_________
APPLICANT'S POSITION:
AFFILIATION DATES:
THIS REFERENCE IS BASED ON:
DIRECT OBSERVATION INDIRECT OBSERVATION
frequent frequent
occasional occasional
infrequent infrequent
DISCUSSION WITH OTHERS WHO HAVE DIRECT KNOWLEDGE
RECORDS ONLY
EVALUATION OF APPLICANT:
Below Unable
Very Average to
Excellent Good Average (*) Assess (*)
DIAGNOSTIC ABILITIES
CLINICAL SKILLS
SURGICAL SKILLS
FUND OF KNOWLEDGE
PATIENT RAPPORT
PEER RAPPORT
MAINTENANCE OF
MEDICAL RECORDS
STAFF MEETING
PARTICIPATION
COMPLIANCE WITH
MEDICAL STAFF BYLAWS/
RULES & REGULATIONS
PRODUCTIVITY
MOTIVATION
INTEGRITY/ETHICS
HEALTH STATUS
(*) Please explain:
ARE YOU AWARE OF ANY SUBSTANCE ABUSE/DEPENDENCY PROBLEMS, CURRENT OR
PAST?
TO YOUR KNOWLEDGE, DOES THIS APPLICANT HAVE ANY MEDICAL MALPRACTICE
SUITS PENDING?
A BRIEF DESCRIPTION OF THIS APPLICANT'S STRENGTHS/WEAKNESSES
SIGNED:______________________________________TITLE:___________
PRINT:
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 60 minutes. This estimate may vary from a low of 30 minutes to a
high of 75 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to the Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.,
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
REQUEST FOR REAPPOINTMENT
TO THE
MEDICAL STAFF
I hereby request reappointment to the medical staff of_____________
(Hospital/Health Center)
_________________________,____________________.
(Town/City) (State)
I request that my clinical privileges be:
____________Renewed as presently granted.
____________Increased as designated in memorandum attached hereto.
____________Reduced as designated in memorandum attached hereto.
Continuing Professional Education: Describe topics, sources, and
dates of all continuing education you have completed in the past year.
Current CPR, ACLS, ATLS, PALS training status:
1. Certified in basic life support?
Certification expires
2. Certified in advanced cardiac life support?
Certification expires
3. Certified in advanced trauma life support?
Certification expires
4. Certified in pediatric advanced life support?
Certification expires
Liability Claims and Adverse Action: If your answer to any of the
following is "yes," please provide full details on an attached separate
sheet if this information has not previously been submitted to this
medical staff:
1. Have there been any previously succesful or any currently pending
challenges to any of your licenses or registrations (State or district,
Drug Enforcement Administration) or the voluntary relinquishment of
licenses or registrations? YES:_____ NO:_____
2. Has your medical staff membership at another hospital been
voluntarily or involuntarily terminated? Have your clinical privileges
at another hospital been voluntarily or involuntarily limited, reduced,
or lost? YES:_____ NO:_____
3. Are you currently or have you been involved in any professional
liability actions? YES:_____ NO:_____
Signature_________________________ Date________________
After review of the applicant's performance, in accordance with the
medical staff bylaws and as summarized in the IHS Work Sheet for
Reappointment to the Medical Staff, I do____; do not____recommend
reappointment to the medical staff. I do____; do not____ recommend
renewal of clinical privileges as requested above.
Comments:
___________________ _________________
Clinical Director Date
I do____; do not____recommend reappointment and privileges as noted
above.
Comments:
___________________ _________________
Service Unit Director Date
Reappointment and privileges are____; are not____approved.
___________________ _________________
Chair of the Governing Body Date
TO BE COMPLETED BY CLINICAL DIRECTOR OR DESIGNEE
INDIAN HEALTH SERVICE
WORK SHEET FOR REAPPOINTMENT
TO THE MEDICAL STAFF OF
________________________,______________________________________,
(Hospital/Health Center) (Town/City) (State)
Name of Applicant:___________________________________________
* Any "no" answer on items 1-14 and any "yes" answers on items 15-23
need to be explained fully on attached page(s).
YES NO
1. Is this applicant physically, mentally, and emotionally capable of
performing the services required of a member of the medical staff and
requested privileges?
2. Has this applicant consistently complied with the medical staff
bylaws, rules, and regulations of this facility?
3. Has this applicant provided verification of current licensure?
4. Have favorable reports been received on this applicant's
professional competence, clinical judgment, and personal character?
5. Are the privileges being sought the same as those currently
granted?
6. Does this applicant relate and work well with other patient care
staff?
7. Is this applicant readily available and responsive when needed?
8. Does this applicant regularly attend medical staff meetings?
9. Has this applicant shown willingness to serve on, or chair,
appropriate committees when asked to do so?
10. When appointed to a committee, has this applicant served in the
capacity to which appointed and attended meetings with appropriate
regularity?
11. Has this applicant willingly participated in the quality
assurance program and functions of this IHS facility?
12. Has this applicant been cooperative in observance of medical
staff and hospital procedural rules?
13. Has this applicant been cooperative in compliance with
established medical records requirements?
14. Has this applicant consistently completed medical records within
prescribed time limits?
15. Have any adverse actions been initiated or any judgments rendered
against this applicant or against the Federal Government on the basis of
this applicant's patient care practices?
16. Has this applicant required counselling due to non-conformance
with standards in his/her clinical practice or medical staff related
activities?
17. Has any disciplinary action been taken against this applicant?
18. Has this applicant exercised any clinical privileges which had
not been granted?
19. Has there been any reduction or revocation of clinical privileges
for this applicant?
20. Has there been any change in the physical, mental, or emotional
health or condition in this applicant?
21. Has this applicant shown evidence of any alcohol or drug abuse or
dependency?
22. Has this applicant had any treatment for alcohol or drug abuse or
dependency?
23. Did the National Practitioner Data Bank query reveal any adverse
information?
24. Relative to the review functions listed, how does this
applicant's performance as a member of the patient care staff compare to
the staff as a whole in numbers of problems attributed to his/her
patient care practices?
Fewer than More than Not
Average Average Average Applicable
a. Monitoring Functions
b. Surgical Case Review
c. Pharmacy & Therapeutics
Review
d. Medical Records Review
e. Blood Usage Review
f. Antibiotic Usage Review
g. Morbidity/Mortality Review
h. Emergency Care Review
i. Infection Control
j. Utilization Review
k. Incidence Reports
l. QA Committee Reports
Quantitate and comment on any "more than average" ratings:
25. Information presented to the Medical Staff Executive Committee?
YES_____ NO_____
Date:___________
26. Comments of Medical Staff Executive Committee:
27. Recommendation of the Medical Staff Executive Committee:
a. _______ Continue membership with privileges as requested,
including requested modifications, if any.
b. _______ Continue membership with same privileges as previously
granted. Changes requested by applicant denied.
c. _______ Continue membership with privileges modified as
recommended by the Medical Staff Executive Committee. (Attach these
recommendations.)
d. _______ Discontinue membership.
CERTIFICATION
I certify that the information provided herein is true and correct to
the best of my knowledge.
__________________ __________________
Date Clinical Director
SUGGESTED PRIVILEGES REQUEST FORMS
Appendix C consists of the following:
1) General information regarding privileges request forms
2) Medical privileges request form
a) Medical privileges request form (categorical method for
ob-gyn privileges)
3) Surgical privileges request form for general surgery and surgical
specialties
4) Psychiatric privileges request form
5) Anesthesia privileges request form
6) Dental privileges request form
7) Optometric privileges request form
8) Psychology privileges request form
9) Audiologic privileges request form
10) Podiatric privileges request form
11) Radiology privileges request form
12) Anatomical and clinical pathology request form
GENERAL INFORMATION REGARDING PRIVILEGES REQUEST FORMS
The granting of clinical privileges must be very individualized to
both the individual clinician and to the facility where the privileges
will be performed. For this reason a standardized privileges form is
not desirable. The two methods most commonly utilized are the explicit
listing of every privilege desired (generally referred to as the
"laundry list") or to group privileges requested by category (see
appendix C.2.a).
In Appendix C, parts 2-9 are a collection of explicit privileges
request forms. Please note that the "Medical Privileges Request Form"
(C.2) is designed more for the generalists performing some functions
within the specialty areas noted. Appendix C.3 is a request form for
general and specialty surgical procedures for physicians in those
respective surgical fields. Facilities need to prepare their own
privileges lists, commensurate with the ability of that individual
facility to support certain procedures or types of medical care.
SAMPLE
INDIAN HEALTH SERVICE
MEDICAL PRIVILEGES REQUEST FORM
INTRODUCTION: This Medical Privileges Request Form must be
accompanied or preceded by a completed application for medical staff
appointment, including the necessary supporting documents. Many
clinical privileges pertinent to the practice of medicine and surgery
are listed below. This list contains both outpatient and inpatient
items. The request for privileges must reflect both the applicant's and
the facility/staff's ability to carry out or support the various
functions. This list is intended primiarily for the generalist
physician or physician extender performing these functions within the
areas listed. Internists, pediatricians, and obstetricians may request
additional appropriate privileges commensurate with their expertise
within their specialty and the facility's ability to support the
requested privileges. They should be presented in an attached list and
referenced on this form under "other."
INSTRUCTIONS FOR COMPLETING THE FORM
APPLICANT: With a check mark in the appropriate location, indicate
for each item your decision to request either 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. "Direct Supervision" may be fulfilled
via telephone consultation, if appropriate. 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 13.
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. Please explain any recommended limitations or denial of
privileges on an attached sheet. Your recommendations are considered by
the Governing Body when granting or not granting privileges.
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 60 minutes. This estimate may vary from a low of 30 minutes to a
high of 75 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
MEDICAL PRIVILEGES REQUEST FORM
Requested Recommended
by by
Applicant Supervisor/
Consultant
L F N L F
T U O T U
D L T D L
L L
I. OBSTETRICS
A. Minor
1. Normal prenatal and postpartum care
2. Normal spontaneous labor and vaginal delivery
3. Midline episiotomy and repair
4. Local and pudendal anesthesia
5. Repair of vaginal and cervical laceration
6. Management of mild preeclampsia
7. Amniotomy
8. Management of postpartum hemorrhage
9. Management of postpartum infection
10. Interpretation of external and internal fetal heart rate
monitor tracings
11. Manual removal of placenta
12. Postpartum uterine exploration and/or curettage
13. Low forceps delivery
14. Curettage for incomplete abortion
15. Other (Specify)
B. Major
1. Multiple pregnancy
2. Amniocentesis
3. Breech delivery
4. Paracervical block
5. Induction or stimulation of labor
6. Cesarean section
7. Mid forceps delivery
8. Management of medical complications in pregnancy, such as
diabetes, severe preeclampsia, renal disease.
9. OB ultrasound
10. Other (Specify)
II. GYNECOLOGY
A. Minor
1. I & D of vulvar or perineal abscess
2. Biopsy of perineum, vulva, cervix, or vagina
3. Endometrial biopsy
4. Insertion and removal of intrauterine device
5. Dilatation and curettage
6. Culdocentesis
7. Polypectomy
8. Vaginal or uterine packing
9. Other (Specify)
B. Major
1. Pelvic exam under anesthesia
2. Tubal ligation
3. Marsupialization of Bartholin's cyst
4. Abdominal hysterectomy
5. Incidental appendectomy
6. Vaginal hysterectomy
7. A & P repair
8. Peritoneoscopy (laparoscopy)
9. Salpingoophorectomy
10. Other (Specify)
III. PEDIATRICS
A. Hepatic and Gastrointestinal Disease
1. Hepatitis
2. Peptic ulcer disease
3. Diarrheas
4. Other (Specify)
B. Renal Disease, Hypertension
1. Acute or chronic glomerulonephritis
2. Nephrotic syndrome
3. Hypertension
4. Chronic renal failure
5. Other (Specify)
C. Pulmonary Disease
1. Uncomplicated asthma
2. Complicated asthma
3. Ventilatory management
4. Pneumonia
5. Cystic fibrosis
6. Other (Specify)
D. Cardiac Disease
1. Nonsurgical congenital heart disease
2. Rheumatic heart disease
3. Heart failure, acute and/or chronic
4. Cardiac arrhythmias
5. Other (Specify)
E. Metabolic and Endocrine Disease
1. Fluid and electrolyte problems
2. Diabetes mellitus
3. Disease of the thyroid gland
4. Menstrual disorders
5. Growth disorders
6. Other (Specify)
F. Rheumatologic Disease
1. Lupus erythematosus
2. Juvenile rheumatoid arthritis
3. Other (Specify)
G. Infectious Disease
1. Septic arthritis
2. Osteomyelitis
3. Urinary tract infection
4. Tuberculosis
5. CNS infections
6. Neonatal sepsis
7. Other (Specify)
H. Hematologic and Oncologic Diseases
1. Anemias
2. Coagulation disorders
3. Thrombocytopenia
4. Cancer chemotherapeutic drugs administration
5. Cancer patient management
6. Transfusion
7. Erythroblastosis
8. Exchange transfusion
9. Other (Specify)
I. Newborn Nursery Care
1. Care of normal infant
2. Care of premature infant
3. Hemolytic disease of newborn
4. Respiratory distress syndrome
5. Neonatal resuscitation/emergency stabilization
6. Other (Specify)
J. Other, Pediatrics
1. Failure to thrive
2. Adolescent gynecology
3. Well child care
4. Convulsive disorders
5. Fever of unknown origin
6. Other (Specify)
IV. MEDICINE
A. Hepatic and Gastrointestinal Disease
1. Cirrhosis
2. Decompensated cirrhosis
3. Hepatitis
4. Cholecystitis
5. Pancreatitis
6. Regional enteritis
7. Ulcerative colitis
8. Peptic ulcer disease
9. Acute G.I. bleeding
10. Other (Specify)
B. Renal Disease
1. Glomerulonephritis
2. Pyelonephritis
3. Nephrosis
4. Acute insufficiency-conservative
5. Chronic insufficiency
6. Other (Specify)
C. Pulmonary Disease
1. Uncomplicated pneumonia
2. Complicated pneumonia
3. Emphysema and chronic bronchitis
4. Pulmonary insufficiency
5. Pulmonary embolus
6. Pneumothorax
7. Ventilator management
8. Oxygen therapy
9. Asthma
10. Other (Specify)
D. Cardiac Disease
1. Electrocardiographic interpretation
2. Congestive heart failure, acute
3. Congestive heart failure, chronic
4. Ischemic heart disease, angina
5. Myocardial infarction, uncomplicated
6. Myocardial infarction, complicated
7. Valvular heart disease
8. Pericarditis
9. Cardiac arrhythmias
10. Cardioversion-medical
11. Cardioversion-electrical
12. Thrombophlebitis
13. Other (Specify)
E. Hypertension
1. Essential hypertension
2. Malignant hypertension
3. Other (Specify)
F. Metabolic and Endocrine Disease
1. Diabetes Mellitus
2. Diabetes Mellitus, complicated by ketoacidosis or coma
3. Hypo - or hyperthyroidism, uncomplicated
4. Hypo - or hyperthyroidism, severe or complicated
5. Gout
6. Other (Specify)
G. Collagen Diseases
1. Lupus erythematosus
2. Scleroderma
3. Other (Specify)
H. Arthritis
1. Rheumatoid arthritis
2. Osteoarthritis
3. Other (Specify)
I. Hematologic, Oncologic Disease
1. Anemias
2. Thrombocytopenias
3. Cancer chemotherapeutic drug administration
4. Cancer patient management
5. Other (Specify)
J. Neurological diseases
1. Cerebrovascular accident
2. Convulsive disorders
3. Parkinsonism
4. Degenerative neurological disorders
5. Meningitis
6. Other (Specify)
K. Allergy (Medical or Pediatric)
1. Desensitization
2. Urticaria
3. Other (Specify)
V. SURGICAL OR PROCEDURAL (See Appendix C3, for Surgical Privileges
Request)
A. Skin
1. I & D of abscess
2. Wound debridement
3. Incisional and excisional biopsy
4. Excision of benign tumors
5. Repair and closure of simple lacerations (not involving
tendons, nerves, or major vessels)
6. Repair and closure of complicated lacerations
7. Electro-surgical destruction of lesions (Fulguration)
8. Pilonidal cyst drainage
9. Lymph node biopsy
10. First and second degree burns
11. Other (Specify)
B. Ophthalmologic
1. I & D abscess of lid
2. Removal of superficial foreign bodies
3. Corneal abrasion
4. Other (Specify)
C. ENT and Plastic Surgery
1. Tracheostomy
2. I & D abscess or hematoma of canal or auricle
3. Foreign body removal from nose or ear
4. Laryngoscopy
5. Nasal packing
6. Nasal fracture reduction
7. Blepharoplasty
8. Myringotomy
9. Other (Specify)
D. Digestive System
1. I & D perirectal abscesses
2. Electrocautery or excision of anal condylomata
3. I & D oral abscesses
4. Biopsy mouth, tongue or lip lesions
5. Repair oral lacerations
6. Passage and use of Sengstaken-Blakemore tube
7. Gastric lavage
8. Liver biopsy, closed
9. Proctosigmoidoscopy, anoscopy
10. Proctosigmoidoscopy, anoscopy, with biopsy
11. Diagnostic paracentesis
12. Therapeutic or decompressive paracentesis
13. Closed reduction of hernias
14. Gastroscopy
15. Other (Specify)
E. Orthopedic
1. Muscle biopsy
2. Injection of tendon sheath, ligaments, trigger points, or
bursae
3. Arthrocentesis
4. Bone marrow aspiration
5. Bone marrow biopsy
6. Closed reduction of simple fractures of phalanges,
clavicles, ribs, toes
7. Closed reduction of simple fractures of radii, ulnae,
humeri, tibiae, fibulae (Circle which applying for)
E. Orthopedic (Continued)
8. Reduction of dislocations of elbows, shoulders, fingers,
hip
9. Application of casts and splints
10. Non-surgical and non-neurological traction
11. Other (Specify)
F. Thoracic
1. Thoracentesis
2. Tube thoracostomy
3. Pleural biopsy
4. Bronchoscopy
5. Other (Specify)
G. Genito-urinary, Renal, Urologic
1. Hemodialysis
2. Peritoneal dialysis
3. Bladder aspiration by needle or catheter
4. Vasectomy
5. Circumcision
6. Meatotomy
7. Bladder irrigation
8. Other (Specify)
H. Neurological
1. Peripheral nerve block
2. Lumbar puncture
3. Local or regional anesthesia administration
4. Observe for head injury
5. Subdural Tap
6. Other (Specify)
I. Vascular
1. Arterial puncture
2. Insertion and monitoring of CVP line
3. Insertion of temporary cardiac pacemaker
4. Cutdown for insertion of catheters
5. Umbilical vein catheterization
6. Umbilical artery catheterization
7. Right heart catheterization
8. Other (Specify)
J. Emergency Procedures, Not Covered Elsewhere
1. Cricothyroidotomy
2. Endotracheal intubation
3. Insertion of oropharyngeal airway
4. Intracardiac injection
5. Pericardiocentesis
6. Peritoneal lavage
7. Use of manual and mechanical resuscitator
8. Use of rotating tourniquets
9. Use of MAST trousers
10. Acute drug overdoses
11. Other (Specify)
VI. PSYCHIATRIC (See Appendix C.4, for Psychiatric Privileges
Request)
A. Anxiety disorders
B. Depression
C. Chronic schizophrenia
D. Substance abuse
E. Hyperactivity in children
F. Other (Specify)
VII. RADIOLOGY (See Appendix C.11, for Radiology Privileges Request)
A. Radiograph interpretation (with report)
B. Ultrasound interpretation (with report)
C. Injection of contrast material (venous, arterial, lymphatic)
D. Performance of x-rays
1. Chest
2. Extremities
3. Others
E. Other (Specify)
Note: All clinicians granted minor or major obstetric privileges
must also be qualified for and granted privileges in newborn
resuscitation and stabilization.
MEDICAL 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
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 60 minutes. This estimate may vary from a low of 30 minutes to a
high of 75 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
MEDICAL PRIVILEGES REQUEST FORM
(CATEGORICAL METHOD FOR OB-GYN PRIVILEGES)
Requested Recommended
by by
Applicant Supervisor/
Consultant
L F N L F
T U O T U
D L T D L
L L
I. OBSTETRICS
Note: All clinicians granted obstetrics privileges must also be
qualified for and granted privileges in newborn resuscitation.
A. Category I: Diagnosis & therapy, with minimal threat to life.
Qualifications: Physicians with minimal formal training in the
specialty, but with training and experience in the care of the specific
conditions, and Certified Nurse Midwives. In either case, clinician has
had at least 30 supervised deliveries.
Examples:
1. Normal prenatal & postpartum care
2. Uncomplicated labor & vaginal delivery
3. Maternal-fetal monitoring (clinical & electronic)
4. Local & pudendal anesthesia
5. Amniotomy
6. Episiotomy & repair of second degree laceration
7. Use of oxytocic drugs after completion of third stage
8. Management of uncomplicated postpartum infection
9. Repair of minor vaginal and cervical laceration
10. Management of mild preeclampsia after consultation with an
Ob/Gyn specialist
11. Other (Specify)
B. Category II: Major diagnosis and therapy, but with no significant
threat to life.
Qualifications: Physicians with significant training in the
specialty related to diagnosis and therapy, i.e., full 3 - 6 months of
training and experience within an approved obstetric training program,
as in an Ob/Gyn or Family Practice Residency, and experience in the care
of the specific conditions.
Fully trained and certified nurse midwives must be able to
demonstrate competence through training and experience to be granted
privileges for manual removal of the placenta and for postpartum uterine
exploration. An individual Certified Nurse Midwife who has had advanced
training and experience may be granted privileges for low vacuum
extraction delivery and/or Level I ultrasound.
Examples:
1. Category I
2. Low forceps or vacuum extractor delivery
3. Manual removal of placenta and postpartum uterine
exploration
4. Repair of third/fourth degree perineal laceration
5. Level I Ultrasound
6. Other (Specify)
C. Category III: Major diagnosis and therapy with possible serious
threat to life.
Qualifications: Physicians with completed residency training in the
specialty or with extensive experience in the care of specific
conditions.
Examples:
1. Categories I and II
2. All vaginal deliveries, including Breech delivery Mid
forceps delivery
3. All cesarean deliveries
4. Amniocentesis
5. All high-risk pregnancies including major medical diseases
complicating pregnancy except intrauterine transfusion
6. Other (Specify)
II. GYNECOLOGY
A. Minor: Physician with minimal formal training in the discipline
but with training and experience in the care of the specific conditions.
Examples:
1. I & D of vulvar or perineal abscess
2. Biopsy of vulva, vagina or cervix
3. Endometrial biopsy
4. Culdocentesis
5. Polypectomy
6. Curettage for incomplete abortion
7. Other (Specify)
B. Major: Physician with completed residency training in the
specialty or with extensive training or experience in the care of the
specific conditions. Radical or exenterative procedures are generally
excluded in the IHS clinical setting
Examples:
1. Minor gynecologic surgery
2. All gynecologic illnesses and complications
3. Examination under anesthesia
4. Tubal sterilization
5. Abdominal hysterectomy
6. Salpingoophorectomy
7. Incidental appendectomy
8. Vaginal hysterectomy
9. Anterior & posterior repair
10. Urethropexy (abdominal and/or vaginal)
11. Laparoscopy
12. Other (Specify)
SAMPLE
INDIAN HEALTH SERVICE
SURGICAL PRIVILEGES REQUEST FORM
FOR GENERAL SURGERY AND SURGICAL SPECIALTIES
INTRODUCTION: This Surgical Privileges Request Form must be
accompanied or preceded by a completed application for medical staff
appointment, including the necessary supporting documents. Many
clinical privileges pertinent to the practice of surgery and surgical
specialties are listed below. This list contains both outpatient and
inpatient items. The request for privileges must reflect both the
applicant's and the facility/staff's ability to carry out or support the
various functions. Documentation of training and/or experience in
performing various surgical procedures must accompany this request. Any
additional privileges may be requested on the Surgical Privileges
Request Form or may be presented in an attached list and referenced on
this form under "other."
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; in general, full surgical privileges require the
completion of an accredited surgical residency. Be sure to sign the
request as indicated on page 6.
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. Please explain any recommended limitations or denial of
privileges on an attached sheet. Your recommendations are considered by
the Governing Body when granting or not granting privileges.
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 60 minutes. This estimate may vary from a low of 30 minutes to a
high of 75 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
SURGICAL PRIVILEGES REQUEST FORM
Requested Recommended
by by
Applicant Supervisor/
Consultant
L F N L F
T U O T U
D L T D L
L L
I. GENERAL SURGERY
A. Skin
1. Skin tumors
2. Split thickness grafts
3. Wolfe grafts
4. Pedicle grafts
5. Skin lacerations
6. Extensive burns
7. Pilonidal cyst
B. Head and Neck
1. Parotid gland surgery
2. Lip and tongue surgery
3. Ranula
4. Epulis
5. Resection of jaw
6. Thyroglossal ducts
7. Branchial clefts
8. Pharyngo-esoph. diverticulum
9. Thyroidectomy
10. Phrenic nerve
C. Abdominal and Rectal
1. Paracentesis
2. Gastroscopy
3. Closure perforated ulcer
4. Other gastric surgery
5. Ramstedt Pyloromyotomy
6. Gallbladder & common duct surgery
7. Pancreatic surgery
8. Splenectomy
9. Small & large bowel surgery
10. Appendectomy
11. Abdomino-perineal resection
12. Abdominal exploratory after work up
13. I & D of intra-abdominal abscess
14. Traumatic laparotomy
15. Simple inguinal hernia
16. Strangulated or recurrent hernia
17. Ventral or femoral hernia
18. Proctosigmoidoscopy
19. Anoscopy
20. Hemorrhoidectomy
21. I & D Perirectal Abscess
22. Fistula in ano
23. Liver biopsy, open
24. Liver biopsy, closed
D. Breast and Thoracic
1. Breast biopsy
2. Simple & radical mastectomy
3. Thoracentesis & closed drainage
4. Rib resection for empyema
5. Thoracoplasty
6. Intrathoracic surgery
7. Surgery of diaphragm
E. Other
1. Hand infections (major)
2. Hand infections (minor)
3. Other (Specify)
II. VASCULAR SURGERY
A. Vein ligation & stripping
B. Major vascular surgery
C. Arterial grafts
D. Other (Specify)
III. OPHTHALMOLOGIC
A. Chalazion
B. Pterygium
C. Enucleation
D. I & D abscess of lid
E. Corneal laceration
F. Plastic on lids
G. Cataract
H. Squint
I. Dacryocystectomy
J. Dacryocystorhinostomy
K. Glaucoma
L. Retinal detachment
M. Laser therapy
N. Other (Specify)
IV. ENT
A. Tracheostomy
B. I & D abscess or hematoma of canal or auricle
C. Laceration repair of nose or auricle
D. Foreign body removal from nose or ear
E. Complex laceration repair of nose, ear, face, or neck
F. Tonsillectomy, adenoidectomy
G. Biopsy lesions of nose or auricle
H. Laryngoscopy
I. Nasal packing
J. Nasal fracture reduction
K. Reconstructive surgery of congenital deformities including facial
abnormalities (i.e., cleft lip and palate)
L. Split thickness skin graft
M. Full thickness skin graft
N. Bone, cartilage, and alloplastic grafts
O. Blepharoplasty
P. Rotation flaps
Q. Myringotomy
R. Myringotomy with tube insertion
S. Excision of rhinophyma
T. Tympanotomy, tympanoplasty
U. Mastoidectomy, simple
V. Middle ear - removal of polyps, stapes mobilization
W. Otoplasty
X. Stapedectomy
Y. Rhinoplasty, septoplasty
Z. Maxillo-facial injury repairs, including fractures
AA. Excision of nasal mucosa, turbinates, polyps
BB. Sinusotomy
CC. Radical mastoidectomy
DD. Palatoplasty
EE. Lip resection
FF. Other (Specify)
V. UROLOGICAL SURGERY
A. Nephrectomy
B. Pyelotomy
C. Ureterotomy
D. Cystostomy
E. Suprapubic prostatic resection
F. Other suprapubic bladder surgery
G. Cystectomy
H. Cystoscopy & retrograde pyelogram
I. Transurethral cysto. & prostate surgery
J. Hydrocele, spermatocele, varicocele
K. Vasectomy
L. Testicular surgery
M. Circumcision & meatotomy
N. Major surgery of penis
O. Other (Specify):
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
SAMPLE
INDIAN HEALTH SERVICE
PSYCHIATRIC PRIVILEGES REQUEST FORM
INTRODUCTION: This Psychiatric Privileges Request Form is designed
primarily for physicians who have completed a residency in psychiatry;
(psychiatric privileges for non-psychiatric physicians are listed in
section VII of the Medical Privileges Request Form). It must be
accompanied or preceded by a completed application for medical staff
appointment, including the necessary supporting documents. Many
clinical privileges pertinent to the practice of psychiatry are listed
below. The request for privileges must reflect both the applicant's and
the facility/staff's ability to carry out or support the various
functions. Any additional requested privileges shall be presented in an
attached list and referenced on this form under "other."
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 6.
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. Please explain any recommended limitations or denial of
privileges on an attached sheet. Your recommendations are considered by
the Governing Body when granting or not granting privileges.
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 60 minutes. This estimate may vary from a low of 30 minutes to a
high of 75 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
PSYCHIATRIC PRIVILEGES REQUEST FORM
Requested Recommended
by by
Applicant Supervisor/
Consultant
L F N L F
T U O T U
D L T D L
L L
I. Major General Psychiatric Privileges
A. Diagnosis and Treatment of Adult:
1. Affective disorders including unipolar and bipolar
affective disorders and dysthymic disorders
2. Schizophrenic disorders (including brief reactive
psychosis)
3. Anxiety disorders
4. Substance use disorders
5. Somatoform disorders
6. Personality disorders and borderline states
7. Other (Specify)
B. Differential diagnosis of organic mental syndromes by
psychiatric, physical, and laboratory techniques
C. Differential diagnosis and treatment of neuropsychiatric
conditions including localizing and diffuse cortical pathology.
D. Differential diagnosis and treatment of emergency psychiatric
conditions, including suicidal, acutely psychotic, non-communicative,
assaultive and drug and alcohol related syndromes
E. Adult Psychopharmacologic use of:
1. Tricyclic antidepressants
2. Mono-amine oxidase inhibitors
3. Non-anaesthetic uses of neuroleptics
4. Benzodiazepines in the treatment of psychiatric disorders
(especially anxiety)
5. Psychomotor stimulants
6. B-blockers for psychiatric use
7. Lithium carbonate or citrate for psychiatric uses
F. Differential diagnosis and treatment of sleep disorders
G. Diagnosis and treatment of psychosexual disorders and
non-physiologic sexual dysfunction
H. Individual psychotherapy of patients
I. Group psychotherapy
J. Family/couple therapy
K. Psychiatric program consultation
L. Psychiatric administrative consultation
M. Diagnosis and treatment of addiction and habituation to DEA
schedule I through V drugs (NOTE: Must conform to DEA regulations)
N. Other (Specify)
II. Child Psychiatric Privileges
A. Diagnosis and treatment in children and adolescents of:
1. Schizophrenia and related disorders
2. Affective disorders
3. Autism
4. Anxiety disorders
5. Personality disorders
6. Psychosexual disorders
7. Substance use disorders
8. Psychological factors affecting physical condition
9. Anorexia nervosa, bulimia, and eating disorders
10. Conduct disorders
11. Attention deficit disorder and hyperactivity
12. Enuresis/encopresis/sleep walking/sleep terror
13. Tics (including Tourette's disorder)
14. Identity disorders
15. Attachment/object relations disorders
16. Other (Specify)
B. Diagnosis and treatment of mental retardation
C. Diagnosis and treatment of developmental delays, learning
disabilities, and specific neuropsychiatric dysfunctional syndromes
D. Use in children, and early adolescent of:
1. Antidepressants
2. Neuroleptics
3. Benzodiazepines
4. Psychomotor stimulants
5. Anticonvulsants for psychiatric purposes
6. Other medications with a primarily psychoactive
pharmacologic effect
7. Other (Specify)
E. Individual psychotherapy, play therapy, behavioral therapy, and
common child therapy
F. Emergency child psychiatric diagnosis and treatment of more
common emergency child psychiatric syndromes, including suicide
attempts, dissociative stages, psychotic presentations, etc.
G. Other (Specify)
II. Minor Psychiatric Privileges
A. Forensic psychiatric privileges in:
1. Civil proceedings:
a) Adult
b) Child
2. Criminal proceedings:
a) Adult
b) Child
B. Use of legally controlled treatment modalities including:
1. Treatment of criminal sexual offenders
2. Use of electro-convulsive therapy
3. Use of investigational drugs in treatment of psychiatric
disorders
4. Other (Specify)
C. Diagnosis and treatment of epilepsy
D. Administration of individual psychological tests (e.g., MMPI,
Bender, WAIS)
E. Treatment of chronic pain and illness behavior syndromes
F. Diagnosis and treatment of culture bound syndromes
G. Other (Specify)
PSYCHIATRIC 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 Executive Committee of the Medical Staff, 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
SAMPLE
INDIAN HEALTH SERVICE
ANESTHESIA PRIVILEGES REQUEST FORM
INTRODUCTION: This Anesthesia Privileges Request Form must be
accompanied or preceded by a completed application for medical staff
appointment, including the necessary supporting documents. Most
clinical privileges pertinent to the practice of anesthesia are listed
below. The request for privileges must reflect both the applicant's and
facility/staff's ability to carry out or support the various functions.
Any additional privileges may be requested on the Anesthesia Privileges
Request Form or may be presented in an attached list and referenced on
this form under "other."
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 6.
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. Please explain any recommended limitations or denial of
privileges on an attached sheet. Your recommendations are considered by
the Governing Body when granting or not granting privileges.
Assignment of clinical privileges in anesthesiology must be based
upon:
1. Education
2. Clinical training
3. Capacity to manage procedurally related complications
The suggested classes of clinical privileges are:
I. CLASS I PRIVILEGES
Such privileges are to be granted to those members of the
medical staff who are permitted to perform local infiltration
anesthesia, topical application, and minor nerve blocks.
II. CLASS II PRIVILEGES
This class of privileges is assigned to those members of the
medical staff who are qualified to perform specific anesthetic
procedures under specified conditions in addition to local
infiltration, topical application, and minor nerve block class.
The Anesthesia Privileges Request Form should be completed for
these privileges.
III. CLASS III PRIVILEGES
Privileges granted to those individuals who by training and
experience are competent in:
A. The management of procedures for rendering a patient
insensible to pain and emotional stress during surgical,
obstetrical, and certain medical procedures;
B. The support of life functions under the stress of
anesthetic and surgical manipulations;
C. The clinical management of the patient unconscious from
whatever cause;
D. The management of problems in pain relief;
E. The management of problems in cardiac and respiratory
resuscitation;
F. The application of specific methods of respiratory therapy;
G. The clinical management of various fluid, electrolyte, and
metabolic disturbances.
When Class III privileges are granted, they should be
accompanied by specific limitations where indicated. The
Anesthesia Privileges Request Form should be completed for these
privileges.
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 60 minutes. This estimate may vary from a low of 30 minutes to a
high of 75 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
ANESTHESIA PRIVILEGES REQUEST FORM
Requested Recommended
by by
Applicant Supervisor/
Consultant
L F N L F
T U O T U
D L T D L
L L
I. General Anesthesia
A. Adult
B. Child
C. Inhalation agents
D. Intravenous agents
II. V Sedation
A. Barbiturates
B. Catamenia
C. Narcotics
D. Major Tranquilizers
III. Regional Anesthesia
A. Subarachnoid block
B. Lumbar epidural block
C. Brachial plexus block
D. Sciatic - Femoral block
E. Ankle block
F. Cervical epidural
G. Thoracic epidural
H. Other (Specify)
IV. Pain Management
A. Differential subarachnoid block
B. Lumbar sympathetic block
C. Stellate ganglion block
D. Epidural steroids
E. Epidural narcotics
F. Celiac plexus block
G. Intercostal nerve block
H. Neurolytic block
V. Subspecialty Anesthesia
A. Infants
1. Routine
2. High risk
B. Thoracic surgery
1. Adult
2. Child
3. Infant
C. Intracranial surgery
1. Adult
2. Child
3. Infant
D. Major vascular surgery
E. Caesarean section
VI. Monitoring
A. Radial artery catheterization
B. CVP line placement
1. Peripheral
2. Internal jugular
3. Subclavian
C. Pulmonary artery catheterization
VII. Special Techniques
A. Deliberate hypotension
B. Deliberate hypothermia
VIII. Airway Management
A. Awake
1. Oral
2. Nasal
B. Anesthetized
1. Oral
2. Nasal
IX. Ventilator Management
X. Interpretation of ABG's
XI. Interpretation of PFT's
XII. Interpretation of EKG's
XII. Supervision of CRNA'S
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 Executive Committee of the Medical Staff, 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
SAMPLE
INDIAN HEALTH SERVICE
DENTAL PRIVILEGES REQUEST FORM
INTRODUCTION: The Dental Privileges Request Form must be accompanied
or preceded by a completed application for medical staff appointment,
including the necessary supporting documents. Most clinical privileges
pertinent to the dental program of your assigned facility are listed
below. The definitions of the privileges are found in the Indian Health
Service document "ADA Code Definitions for the IHS Direct Care Program."
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 dental
community at large. Be sure to sign the request as indicated on page 5.
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. Please explain any recommended limitations or denial of
privileges on an attached sheet. Your recommendations are considered by
the Governing Body when granting or not granting privileges.
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 20 minutes. This estimate may vary from a low of 10 minutes to a
high of 30 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, S.W., Washington, DC
20201; and to the Paperwork Reduction Project, (0917- ), Office of
Management and Budget, Washington, DC 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
DENTAL PRIVILEGES REQUEST FORM
Requested Recommended
by by
Applicant Supervisor/
Consultant
L F N L F
T U O T U
D L T D L
L L
I. ENDODONTIC PROCEDURES
A. Anterior Root Canal Therapy
B. Bicuspid Root Canal Therapy
C. Molar Root Canal Therapy
D. Endodontic surgery
II. PERIODONTICS
A. Mucogingival Surgery
B. Osseous Surgery
C. Osseous Graft
D. Free Soft Tissue Grafts
E. Splinting
F. Occlusal Adjustment Limited
G. Occlusal Adjustment - Complete
H. Special Periodontal Appliances (occlusal guard)
III. REMOVABLE PROSTHODONTICS
A. Complete Dentures
B. Immediate Dentures
C. Partial Dentures
D. Obturator for Cleft Palate
E. Overdenture - Complete/Partial
F. Special Appliances (Specify)
IV. ORAL SURGERY
A. Routine Tooth Extractions
B. Surgical Extraction of Erupted Tooth
C. Surgical Extraction - Tissue Impaction
D. Surgical Extraction - Bone Impaction
E. Surgical Extraction - Impaction Requiring Sectioning of Tooth
F. Residual Root Recovery by Surgery
G. Oral Antral Fistula Closure
H. Antral Root Recovery
I. Tooth Replantation
J. Tooth Transplantation
K. Surgical Exposure of Impacted or Unerupted Tooth for Orthodontic
Reasons
L. Surgical Exposure of Impacted or Unerupted Tooth to Aid Eruption
M. Biopsy of Oral Tissue (hard)
N. Biopsy of Oral Tissue (soft)
O. Alveoloplasty per Quadrant in Conjunction with Extractions
P. Alveoloplasty per Quadrant not in Conjunction with Extractions
Q. Stomatoplasty per Arch - Uncomplicated
R. Stomatoplasty per Arch - Complicated
S. Surgical Excision
T. Destruction of Lesion by Physical Methods (electrosurgery)
U. Removal of Exostosis - Maxilla or Mandible
V. Incision & Drainage of Abscess - Intraoral
W. Incision & Drainage of Abscess - Extraoral
X. Removal of Foreign Body, Skin, or Subcutaneous Aveolar Tissue
Y. Maxilla Closed Reduction, Teeth Immobilized (if present)
Z. Mandible Open Reduction (Intraoral)
AA. Mandible Closed Reduction
BB. Malar/Zygomatic Arch Closed Reduction
CC. Alveolus Stabilization of Teeth, Open Reduction,
Splinting
DD. Closed Reduction of TMJ Dislocation
EE. Frenulectomy
FF. Emergency Tracheotomy
GG. Suturing of Traumatic Wounds (intraoral)
HH. Suturing of Traumatic Wounds (extraoral)
V. ORTHODONTICS
A. Removable Appliance - Maxillary Arch
B. Removable Appliance - Mandibular Arch
C. Fixed Appliances - Maxillary Arch (minor tooth movement)
D. Fixed Appliance - Mandibular Arch (minor tooth movement)
E. Functional Appliances
F. Comprehensive Orthodontic Treatment
VI. ADJUNCTIVE SERVICES
A. N2O Analgesia
B. IV Sedation
C. Therapeutic Drug Injection
D. Oral Sedation
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
SAMPLE
INDIAN HEALTH SERVICE
OPTOMETRIC PRIVILEGES REQUEST FORM
INTRODUCTION: The Optometrist clinical privilege application must be
accompanied, or preceded, by a completed application for medical staff
appointment, including the necessary supporting documents. The most
common privileges practiced by optometrists will be found in this
document, but many may still have to be added by the applicant. This
can be done by "writing in" additional privileges on the bottom of page.
INSTRUCTIONS FOR COMPLETING THE FORM
APPLICANT: With a check mark in the appropriate location, indicate
for each item if privileges are requested. Be sure to sign the request
as indicated on page 5.
DISCIPLINE SPECIFIC SUPERVISOR OR AREA OPTOMETRY CONSULTANT:
Indicate your recommendation for each requested clinical privilege by
placing a check mark in the appropriate location. This recommendation
is considered by the privilege granting authority. Be sure to sign the
request as indicated on page 4. Recommended limitations or denial of
privileges must be explained in detail on an attached sheet.
NOTE: Any patient admitted to an IHS hospital for ocular procedures
must have an admission history and physical exam conducted by a
physician member of that hospital's medical staff. Any non-ocular
medical problem(s) present on admission, and any which occur during the
hospital stay, must be evaluated and managed by a physician member of
that hospital's medical staff.
CREDENTIALS AS EVIDENCE OF COMPETENCY:
I. Class I optometric privileges:
A. EDUCATION: A Degree of Doctor of Optometry is required from one
of the schools or colleges of optometry listed as accredited by the
Council on Optometric Education of the American Optometric Association.
B. LICENSURE: Full and unrestricted license is required to practice
optometry in a State, territory, or District of Columbia, if hired as a
civil servant. A commissioned officer of the U.S. Public Health Service
(USPHS) must meet the USPHS Optometry appointment standards.
II. CLASS II optometric privileges:
An optometrist is eligible for additional clinical privileges, if the
following credentials are provided:
A. A license to practice optometry and State certification to use
therapeutic pharmaceutical agents.
B. If (A) is not satisfied, evidence of one or more of the following
is required:
1. Training or experience such that the optometrist now holds
IHS privileges or equivalent, consistent with appropriate portions
of class II privileges, and these privileges have been held and
regularly reviewed over the prior two or more years.
2. Successful completion of at least 1 year of post-graduate
training in a primary care residency or fellowship program
accredited by the Council on Optometric Education of the American
Optometric Association.
3. Diplomate of the American Academy of Optometry in ocular
disease in primary care.
4. Successful completion of a minimum 106-hour course in the
management of ocular diseases and/or conditions as certified by an
accredited optometric educational institution.
5. A passing score on a national certifying examination in the
treatment and management of ocular diseases and/or conditions.
OMB No: 0917-0009
Expires: 11/30/94
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
The public reporting burden for completing this form is estimated to
be 20 minutes. This estimate may vary from a low of 10 minutes to a
high of 30 minutes per response. This burden time estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information including
suggestions for reducing this burden to Reports Clearance Officer,
Attention: PRA, United States Public Health Service, Hubert H. Humphrey
Building, Room 721-B, 200 Independence Avenue, SW, Washington, D.C.
20201; and to the Paperwork Reduction Project, (0917-0009), Office of
Management and Budget, Washington, D.C. 20503. DO NOT SEND COMPLETED
FORMS TO EITHER OF THESE TWO ADDRESSES.
OPTOMETRIC PRIVILEGES REQUEST FORM
REQUESTED RECOMMENDED
BY BY SU
APPLICANT SUPERVISOR/OD
CONSULTANT*
L F N L F
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