Form 0917-0009-11 OMB 0917-0009-11, Psychology Privileges Request Form

Circular Appendix 95–16–C.8 (04/10)
Page 4 of 4

Psychology PRIVILEGES REQUEST FORM

INTRODUCTION

This Psychology 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 psychology are listed below.

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 clinical psychology community at large. Be sure to sign the request as indicated on page 4.

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 (N.R.). 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.

I. CLinical Attending Privileges

A. Patient Management Privileges	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Admit patients
Discharge patients
Coordinate/provide psychological care
Write and sign treatment plans
Write orders for assessment and treatment procedures
Write orders for medical consultation
Participate on multi-disciplinary treatment teams
Enter consultation notes on charts
9. Other (specify):

B. Clinical Assessment Privileges	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Behavioral assessment
Biobehavioral and psychophysiological assessment exam­inations
Neuropsychological examination
Mental status examination
Intellectual assessment
Developmental assessment
Personality assessment
Trauma assessment
Differential diagnostic assessment
Forensic assessment
Psychopharmacologic response monitoring
Vocational/education assessment
Psychosocial assessment
14. Other assessment, as indicated

C. Clinical Treatment Privileges	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Individual psychotherapy
Group psychotherapy
Family psychotherapy
Behavior modification
Hypnosis
Biofeedback
Emergency room/crisis intervention
Pain management
Substance abuse reduction
Stress management
Rehabilitation services
12. Other (specify):

II. Consulting Privileges

A. Within the Facility	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Consultation liaison to other services
Organizational developmental services
Staff development
Wellness promotion

B. External to the Facility	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Professional and community education
Community development
Disease/injury prevention

III. Programmatic Activities	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Program planning and evaluation
Collection/interpretation of caseload date
Ascertainment of population mental health needs
Supervise staff and trainees
Ensure accreditation/approval

Psychology 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

Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 10 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer, Indian Health Service, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852, ATTN: PRA (0917–0009). Please do not send this form to this address.