<p> Northwest Health Services, Inc.</p><p>Provider Request/Renewal for Clinical Privileges</p><p>Check category of applicant: Name:______( ) Physician - Family Practice ( ) Pediatrician ( ) Physician - Internal Medicine ( ) Psychiatrist ( ) Physician - GYN ( ) Surgeon ( ) Physician - General Practice ( ) Nurse Practitioner ( ) Physician Assistant</p><p>Procedure Provider’s Granted Denied Additional Request (Date) (Date) Requirements Respiratory Spirometry</p><p>Gastroenterlogy Colonoscopy Sigmoidoscopy EGD</p><p>Pediatrics Circumcisions Safe exams</p><p>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</p><p>QI Committee\Providers Privileging Request Renewal.doc - 08/04 1 Northwest Health Services, Inc.</p><p>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</p><p>GYN Endometrial bx LEEP Fit for diaphragms KOH smear Wet prep I&D Bartholins cyst</p><p>Ophthalmology Removal of foreign body Woods lamp exam</p><p>Others:</p><p>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</p><p>I have approved the requested procedures for the above Nurse Practitioner. ______Collaborating Physician (Print) Provider Signature Date</p><p>Recommended to Board of Directors for Approval/Denial ______Chief Medical Officer Signature Date</p><p>QI Committee\Providers Privileging Request Renewal.doc - 08/04 2 Northwest Health Services, Inc.</p><p>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</p><p>GYN Endometrial bx LEEP Fit for diaphragms KOH smear Wet prep I&D Bartholins cyst</p><p>Ophthalmology Removal of foreign body Woods lamp exam</p><p>Others:</p><p>Additional Requirements Needed: ______</p><p>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.</p><p>______Provider Name (Print) Provider Signature Date</p><p>Recommended to Board of Directors for Approval/Denial</p><p>QI Committee\Providers Privileging Request Renewal.doc - 08/04 3 Northwest Health Services, Inc.</p><p>______Chief Medical Officer Signature Date</p><p>Board Approved:______Date NHS’ Board President Signature</p><p>QI Committee\Providers Privileging Request Renewal.doc - 08/04 4</p>