UC Davis, Student Health and Counseling Services 180-02 Appointment & Reappointment/AHP

UC Davis, Student Health and Counseling Services 180-02 Appointment & Reappointment/AHP Attachment 5

OPTOMETRIST PRIVILEGE DELINEATION FORM

This privilege form describes the qualifications related to competency to exercise the defined clinical privileges that may be requested by a qualified practitioner based on the training and experience required. Privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, staff, and other support required to provide the services defined in this document. The applicant must also adhere to any additional organizational, regulatory, or accrediting requirements that this facility is obligated to meet.

NAME: (Please Print)

Instructions: Please check off the “Requested” box for all privileges requested. If you wish to exclude any procedures, please strikethrough, initial and date those procedures that you DO NOT wish to request.

Proctor Initial Criteria Renewal Criteria Requested Privileges Requirements

 CORE PRIVILEGES 1. Comprehensive evaluation of the eye and its adnexa,  Graduation from an  Minimum of  Five (5) diagnosis, and treatment of visual disorders and accredited Optometry fifteen (15) cases chart anomalies. Program with a Doctor of as evidenced by reviews. 2. General and ophthalmic medical history Optometry degree; AND the facility EHR in 3. Visual acuity evaluation the prior three (3) years. 4. Lensometry  Active and Current License with the CA Measurements, e.g., pupillary distance, near point of 5. Board of Optometry convergence, exophthalmos, and accommodation 6. Ocular motility evaluations 7. Stereopsis and depth perception evaluation 8. Evaluation of pupillary reflexes 9. Color vision assessment 10. Evaluation of binocular function 11. Spectacle prescribing 12. Contact lens fitting, prescription, follow-up care and modifications 13. Pupil dilation 14. Examination of the eye using slit lamp biomicroscopy and goniolens 15. Fundus examination of the peripheral retina using indirect ophthalmoscopy (with scleral depression when necessary) and fundus lenses 16. Diagnosis, treatment with topically applied medications, and management of diseases and conditions of the eye and adnexa 17. Conduct and interpret visual field tests 18. Refractions, manifest and cycloplegic 19. Tonometry, contact and non-contact

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OPTOMETRIST PRIVILEGE DELINEATION FORM

I certify that I have had the necessary training and experience to perform the procedures that I have requested. The burden of producing information deemed adequate by the organization for a proper evaluation of current competence, current clinical activity and other qualifications and for resolving any doubts related to qualifications for the requested privileges is mine. I have reviewed all the criteria that pertain to those privileges that I am requesting and I certify that I meet those criteria.

In exercising the privileges granted to me, I agree to strictly abide by the facility’s Credentialing Policies and Procedures.

Applicant’s name: Signature and Print Date

RECOMMENDATIONS/APPROVAL

I have reviewed the applicant’s credentials, experience, training, health status, current competence and peer recommendations relative to this request for privileges. The following recommendations are made:

Supervisor ______Date ___/____/____  APPROVED DENIED  DEFERRED

Medical Director______Date ___/____/____  APPROVED DENIED  DEFERRED

Peer Review Chair______Date ___/____/____  APPROVED DENIED  DEFERRED

Executive Director ______Date ___/____/____  APPROVED DENIED  DEFERRED

Privileges Effective: From ___/____/____ to ___/____/____ (not to exceed appointment date)

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