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Privilege Request Form

1) This document outlines the initial qualifications, core privileges, and renewal qualifications for granting clinical privileges in palliative medicine at North Colorado Medical Center. 2) The initial qualifications include having an MD or DO degree, completing an accredited residency program, and being board certified in hospice and palliative medicine. 3) The core palliative medicine privileges include evaluating patients, forming treatment plans, prescribing medications, and coordinating palliative services, but not pain management privileges which must be requested separately. 4) The renewal qualifications require demonstrated competence within the previous credentialing cycle and compliance with continuing education and other policy requirements.

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Meraj Hussain
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837 views1 page

Privilege Request Form

1) This document outlines the initial qualifications, core privileges, and renewal qualifications for granting clinical privileges in palliative medicine at North Colorado Medical Center. 2) The initial qualifications include having an MD or DO degree, completing an accredited residency program, and being board certified in hospice and palliative medicine. 3) The core palliative medicine privileges include evaluating patients, forming treatment plans, prescribing medications, and coordinating palliative services, but not pain management privileges which must be requested separately. 4) The renewal qualifications require demonstrated competence within the previous credentialing cycle and compliance with continuing education and other policy requirements.

Uploaded by

Meraj Hussain
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

North Colorado Medical Center PALLIATIVE MEDICINE Criteria for Granting Clinical Privileges/Privilege Request Form

Initial Qualifications

Doctor of Medicine or Osteopathy; AND Successful completion of an ACGME or AOA accredited residency training program in a primary medical specialty ; AND

Board certification in Hospice and Palliative Medicine by the American Board of Hospice and Palliative Medicine (prior to 2008); or American Board of Medical Specialties (after 2008) or be actively participating in the process to obtain certification via an ABMS approved specialty.
Demonstrate completion of an approved program in Palliative Medicine or the equivalent in practice experience AND; Current competence as verified through references.

Palliative Medicine Core Privileges


_____ I hereby request CORE PALLIATIVE MEDICINE privileges as follows: Palliative medicine includes the evaluation, consultation and provision of palliative care services to patients with serious or life-threatening illnesses. Core privileges include, but are not limited to, the following: Gathering a history Performing physical examinations Assessing pertinent diagnostic studies Participating in patient and family care planning meetings Forming a treatment plan Directing treatment Prescribing medication Prescribing and coordinating palliative services Performing pain-relieving procedures not included as part of the separate Pain Management Criteria PRIVILEGES FOR THE FOLLOWING MUST BE REQUESTED SEPARATELY: Pain Management

Renewal Qualifications
1) 2) Demonstrated competence and evidence of performing Palliative Medicine privileges within the previous credentialing cycle; AND Evidence of compliance with applicable CME requirements and other established NCMC Medical Staff and/or administrative/operational policies, procedures, regulations and guidelines.

I understand that in making this request I am bound by the Medical Staff Bylaws and the applicable policies of NCMC, and I hereby, stipulate that I meet the established criteria for each request. _______________________________________________ Signature _______________________________________________ Printed Name
Adopted by Department of Medicine: 12/07/07 Approved by BH BOD: Approved by Credentials Committee: 01/02/08 Revised: Approved by Medical Executive Committee:

_______________________ Date

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