Form 0917-0009-14 OMB No. 0917-0009-14, Radiolgy Privileges Request Form

Circular Appendix 95–16–C.11 (04/10)
Page 4 of 4

RADIOLOGY PRIVILEGES REQUEST FORM

INTRODUCTION

The Radiology Privileges Request Form must be accompanied or preceded by a complete application for medical staff appointment, including the necessary supporting documents. Many clinical privileges pertinent to the practice of radiology are listed below. The request for privileges must reflect both the applicant’s and the facility’s/staff’s ability to carry out or support the various functions. Documentation of training and/or experience in performing various procedures/modalities must accompany this request. Any additional privileges may be requested on the form or may be presented in an attached list.

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item whether you are requesting 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. 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 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. This recommendation is considered by the governing body when granting or not granting privileges.

I. RADIOGRAPHIC EXAMINATIONS	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
General diagnostic roentgenology
Barium studies, including small bowel enterolysis and air-contrast barium enemas
Intravenous pyelography
Fistula and sinus tract studies
Myelography (cervical, lumbar, & thoracic)
Other (specify):

II. COMPUTERIZED TOMOGRAPHIC EXAMINATIONS	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Head (including temporal bone and pituitary)
Neck (including salivary glands, and larynx)
Chest
Abdomen
Pelvis
Spine
Extremities
Other (specify):

III. Ultrasound	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Aortic sonography
Obstetrical sonography
Biophysical profile
Gallbladder sonography
Liver sonography
Pancreatic sonography
Splenic sonography
Pelvic sonography
Renal sonography
Thyroid sonography
Vascular sonography
Deep venous (abd/extrem, etc.)
Carotid
Sonography of soft tissue masses or fluid collections
Sonography for thoracentesis guidance
Sonography for guidance of other needle aspiration or biopsy
Sonography for placement of indwelling catheters (nephrostomy, gall bladder)
Other (specify):

IV. MAMMOGRAPHY	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Mammogram interpretation
Needle localization for biopsy
Galactography

V. SPECIAL PROCEDURES	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Abscess drainage
B. Drainage of fluid collections
C. Biopsy/fine needle aspirates
D. Arthrography:
1. Shoulder
2. Wrist
3. Knee
E. Percutaneous gallstone removal
F. Percutaneous nephrostomy tube placement
G. Percutaneous biliary drainage tube placement
H. Percutaneous transhepatic cholangiography
I. Venography
J. Other (specify):

RADIOLOGY 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 20 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.