Form 0917-0009-13 OMB Form No. 0917-0009-14, Podiatric Privileges Request

Circular Appendix 95–16–C.10 (04/10)
Page 3 of 3

Podiatric PRIVILEGES REQUEST FORM

INTRODUCTION

This Podiatric 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 podiatry and podiatric surgery are listed below. This list contains both outpatient and inpatient items, and 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.

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item, if you are requesting privileges. Be sure to sign the request as indicated on page 3.

Discipline-specific supervisor or consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location. 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.

Note: Any patient admitted to an IHS hospital for inpatient podiatric surgery or care must, by prior agreement, have an admission history and physical exam done by a physician member of that hospital’s medical staff. Any medical problems present on admission and any which occur during the hospital stay must be managed by that physician or his/her physician designee. Any patient undergoing outpatient podiatric surgery in any IHS facility must likewise be under the care of one of that facility’s physician members of the medical staff for medical needs.

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Office-based, nonsurgical podiatric care, including examinations, consultation, and noninvasive procedures
Toenail surgery, including removal
Arthroplasty of the lesser digits
Simple cutaneous lesions excision
Simple tenotomy/capsulotomy of the forefoot
Simple bunionectomy
Complex bunionectomy (Keller, Mitchell, Chevian, etc.)
Removal of foreign bodies
Excision of neuromas
Forefoot sesamoidectomy
Tailor's bunionectomy
Excision of dorsal metatarsal cuneiform exostosis
Osteotomy of the lesser metatarsals
Plantar condylectomy, lesser metatarsals
Excision or resection, metatarsal-phalangeal arthroplasty or hemi-arthroplasty of the lesser toes
Excision of subcutaneous lesions, including lipomas, fibromas, and ganglions
Ostectomy of the lesser toe phalanges
Interphalangeal excision arthroplasty or arthrodesis

Podiatric 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

G

Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 5 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.

overning Body