Internal Medicine/Nephrology Page 1 KALEIDA HEALTH

Name: ______Date: ______

INTERNAL MEDICINE SUBSPECIALTY – NEPHROLOGY

PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive.

1. Minimal requirement is successful completion of an ACGME accredited, AOA, Royal College of Physicians and Surgeons of Canada, or an ACGME equivalent Nephrology Fellowship program.

2. Must be Board certified in Nephrology or become Board Certified within 2 years of initial appointment (maintenance of Board Certification is mandatory for all providers who have achieved this status) and Comply with all other requirements of the Medical Staff.

* If Moderate/Conscious Sedation privileges are required to perform a privilege, please request Conscious Sedation privileges as listed on the Internal Medicine Delineation of Privileges or you must invite a Kaleida health Anesthesiologist to participate in the procedure.

With Following NEPHROLOGY - LEVEL I PRIVILEGES PHYSICIAN Not Requirements** REQUEST Granted Granted* (Provide Details)

Consultation Hemodialysis CRT(continuous renal replacement therapy) Peritoneal dialysis (all types) Aphoresis With Following NEPHROLOGY - LEVEL II PHYSICIAN Not Requirements** PRIVILEGES REQUEST Granted Granted* (Provide Details) General Procedures

*Percutaneous renal biopsy with imaging guidance (The total number of ultrasound-guided renal biopsies performed during fellowship, and any done thereafter as practitioner or faculty member must be listed) Requirement: Nephrology Fellowship and 5 cases within the last two years for initial and reappointment.

IM-Nephrology 8-2018

Internal Medicine/Nephrology Page 2

KEY *NOT GRANTED DUE TO: **WITH FOLLOWING REQUIREMENTS Provide Details Below Provide Details Below

1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define)

DETAILS:______

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National Practitioner Databank Disclaimer Statement Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq.)

/ / Signature of Applicant Date Signature of Chief of Service Date

APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS

IM-Nephrology 8-2018