Enter the appropriate provider code in the column marked requested. Name of provider (last, first, mi) 2. To be eligible for core privileges in neurology, the applicant must meet the following qualifications:
DA Form 54401 Download Printable PDF or Fill Online
Current certification or active participation in the examination process leading to certification in
• md, do, or equivalent degree • successfully completed a transitional training year (or equivalent) and residency.
The proponent agency is otsg. “core” privileges cannot be amended or altered in any way. Name of provider (last, first, mi)2. Applicants requesting privileges should only request those privileges when the.
Use the grid below to find, review, and request privileges.
(2) ordering of diagnostic imaging tests Documentation of all privileges must be provided for all privileges on the last page of this form. Clinical privilege delineation is essential in assuring quality care. To be granted these privileges in ultrasound in the dept of emergency medicine, physicians must have both basic and specific qualifications.
The proponent agency is otsg.
The proponent agency is otsg. This will include managing patients with complex, acute, and chronic health conditions and may be in a variety of clinical settings. Department of internal medicine / nephrology. Core privileges for nurse practitioners includes the admission, diagnostic evaluation, consultation and treatment of patients of all ages as delegated by an attending physician.
The proponent agency is otsg.
Initial the recommended column for approved privileges. These requirements conform to the guidelines set forth by the american college of emergency physicians (2001 and 2008). If applicable, check off the “not recommended” boxes. Name of provider (last, first, mi)2.
Department of physical medicine and rehabilitation.
Your signature is required at the end of section i. These privileges may be applied for individually. _____ please print or type. Practitioners may request privileges at initial appointment, reappointment, or during the interim for privileges not previously granted.
Each category and/or individual privilege listed must be coded.
Applicant’s name date first mi last. Department of radiology privileges page 4 procedural sedation noncore privileges q requested note: Delineation of privileges for neurology name: Core privileges (pdf) pain management (pdf) acupuncture.
Each privilege describes minimum requirements for fulfillment as well as documentation requirements.
The proponent agency is otsg. For procedures listed, line through and initial any criteria/applications that do not apply. If you require procedural sedation privileges, please complete the procedural sedation dop request form under “application documents” on the hahv.org website. Physicians must apply for “core” privileges in order to be eligible for clinical privileges in the specialty of neurolo gy at any facility within atrium health.
Shaded areas indicate that the privilege is not applicable for that particular entity.
Minimum training and experience attending physiatrists must have: Check the box corresponding to the privileges that you are requesting. Facility provider codes supervisor codes requested approved requested approved diagnosis and management of: Delineation of privileges department of neurosurgery.
Delineation of privileges form specialty of neurology page 3 print name note 1:
Yes no* i have participated in direct patient care in the hospital setting within the past two (2) years.
