Request/Renewal for Clinical Privileges

Northwest Health Services, Inc.

Provider Request/Renewal for Clinical Privileges

Check category of applicant: Name:______( ) Physician - Family Practice ( ) Pediatrician ( ) Physician - Internal Medicine ( ) Psychiatrist ( ) Physician - GYN ( ) Surgeon ( ) Physician - General Practice ( ) Nurse Practitioner ( ) Physician Assistant

Procedure Provider’s Granted Denied Additional Request (Date) (Date) Requirements Respiratory Spirometry

Gastroenterlogy Colonoscopy Sigmoidoscopy EGD

Pediatrics Circumcisions Safe exams

General ACLS BLS Digital blocks Punch bx I & D cysts Cryotherapy Electrocautery Ingrown toenail removal Simple wound debridement Arthrocentesis (knee, hip, A/C, shoulder) Trigger Point (elbow, back, wrist, fingers) Laceration repair (simple/ intermediate/complex) Evacuation of thrombosed hemorrhoid

QI Committee\Providers Privileging Request Renewal.doc - 08/04 1 Northwest Health Services, Inc.

Procedure Provider’s Granted Denied Additional Request (Date) (Date) Requirements Orthopedics Joint injections X-ray evaluation Simple reduction Casting Shoulder dislocations Nursemaid elbow reduction Patellar reduction

GYN Endometrial bx LEEP Fit for diaphragms KOH smear Wet prep I&D Bartholins cyst

Ophthalmology Removal of foreign body Woods lamp exam

Others:

Additional Requirements Needed: ______I certify that I have no physical or mental conditions that may prevent me from performing the above requested services and procedures in a safe and therapeutic manner. ______Provider Name (Print) Provider Signature Date

I have approved the requested procedures for the above Nurse Practitioner. ______Collaborating Physician (Print) Provider Signature Date

Recommended to Board of Directors for Approval/Denial ______Chief Medical Officer Signature Date

Board Approved:______Date NHS’ Board President Signature Procedure Provider’s Granted Denied Additional Request (Date) (Date) Requirements Orthopedics Joint injections X-ray evaluation Simple reduction Casting Shoulder dislocations Nursemaid elbow reduction Patellar reduction

GYN Endometrial bx LEEP Fit for diaphragms KOH smear Wet prep I&D Bartholins cyst

Ophthalmology Removal of foreign body Woods lamp exam

Others:

Additional Requirements Needed: ______

I certify that I have no physical or mental conditions that may prevent me from performing the above requested services and procedures in a safe and therapeutic manner.

______Provider Name (Print) Provider Signature Date

Recommended to Board of Directors for Approval/Denial

______Chief Medical Officer Signature Date

Board Approved:______Date NHS’ Board President Signature

QI Committee\Providers Privileging Request Renewal.doc - 08/04 4