DEPARTMENT OF SURGERY
REQUEST FOR SPECIFIC PRIVILEGES
GROUP 11
1.00 / General Surgery1.01 / ☐ / Abdominal Procedures
1.02 / ☐ / Abdominal Perineal Resection
1.03 / ☐ / Appendectomy
1.04 / ☐ / Hernia Repair, Diaphragmatic
1.05 / ☐ / Hernia Repair, Femoral
1.06 / ☐ / Hernia Repair, Incisional
1.07 / ☐ / Hernia Repair, Inguinal
1.08 / ☐ / Hernia Repair, Umbilical
1.09 / ☐ / Other Hernia
1.10 / ☐ / Staging Laparotomy
☐
1.20 / ☐ / Operations on Biliary Tract
1.21 / ☐ / Gallbladder
1.22 / ☐ / Intestinal Tract
1.23 / ☐ / Pancreas
1.24 / ☐ / Peritoneum, Omentum
1.25 / ☐ / Spleen
1.26 / ☐ / Paracentesis
1.27 / ☐ / Stomach
1.28 / ☐ / Liver
1.29 / ☐ / Vagotomy
1.30 / ☐ / Cystotomy
1.35 / Breasts
1.36 / ☐ / Excision of Cyst or Tumor
1.37 / ☐ / Incision and Drainage of Abscess
1.38 / ☐ / Mastectomy, Simple
1.39 / ☐ / Mastectomy, Radical
1.40 / ☐ / Reduction/Augmentation Mammoplasty
1.41 / ☐ / Subcutaneous Mastectomy
1.42 / ☐ / Post-Mastectomy Breast Reconstruction
1.43 / ☐ / Gynecomastia
1.50 / Esophagus
1.51 / ☐ / Repair Trauma of Esophagus
1.52 / ☐ / Dilation with Bougies
1.53 / ☐ / Esophageal Resection
1.54 / ☐ / Trauma & Repair of Lacerations
1.55 / ☐ / Esophagectomy
1.56 / ☐ / Tracheoesophageal Fistula
1.57 / ☐ / Esophageal Atresia Repair, Excise Duplications
1.60 / Blood Vessels - Anastomoses
1.61 / ☐ / Aneurysmectomy
1.62 / ☐ / Embolectomy
1.63 / ☐ / Phlebectomy
1.64 / ☐ / Phlebotomy
1.65 / ☐ / Thrombectomy
1.66 / ☐ / Vein Ligation
1.67 / ☐ / Trauma & Repair of Blood Vessel Lacerations
1.68 / ☐ / Endarterectomy
1.69 / ☐ / Extra-Anatomical Bypass
1.70 / ☐ / Carotid Surgery
1.71 / ☐ / Surgery for Occlusive Disease
1.72 / ☐ / AV Fistulae
1.73 / ☐ / Angioplasty; Diagnostic/Catheter Directed Arteriography; Endovascular Stenting
1.75 / Lymph Channels & Nodes
1.76 / ☐ / Biopsy
1.77 / ☐ / Incision and Drainage
1.78 / ☐ / Excision
1.79 / ☐ / Regional Node Dissection
1.80 / Skin and Subcutaneous Tissue
1.81 / ☐ / Biopsy
1.82 / ☐ / Burns, First
1.83 / ☐ / Burns, Second and Third Degree
1.84 / ☐ / Excision Lesion (Cyst, Lipomata, Polyps, etc.)
1.85 / ☐ / Graft, Pedicle
1.86 / ☐ / Graft, Tubular
1.87 / ☐ / Incision and Drainage (Abscesses, Paronychia)
1.88 / ☐ / Deep Abscess (Thyroglossal Cyst, etc.)
1.89 / ☐ / Suture, Uncomplicated Wounds
1.90 / ☐ / Repair Complicated Wounds
1.91 / ☐ / Myocutaneous Flaps
1.95 / Thyroid
1.96 / ☐ / Reopening of Wound for Hemorrhage Control
1.97 / ☐ / Thyroidectomy
1.98 / ☐ / Parathyroid Surgery
2.00 / Chest Surgery
2.01 / ☐ / Cardiovascular Surgery
2.02 / ☐ / Collapse Therapy
2.03 / ☐ / Drainage, Closed
2.04 / ☐ / Drainage, Open
2.05 / ☐ / Lobectomy
2.06 / ☐ / Phrenic Nerve Surgery
2.07 / ☐ / Pneumonectomy
2.08 / ☐ / Scalenotomy
2.09 / ☐ / Thoracentesis
2.10 / ☐ / Thoracic-Abdominal Incision
2.11 / ☐ / Major Chest Surgery
2.12 / ☐ / Emergency Thoracotomy (Open/Closed)
2.13 / ☐ / Major Chest Surgery for Trauma
2.14 / ☐ / Ligation of Ductus Arteriosus
2.15 / ☐ / Median Sternotomy
2.16 / ☐ / Pericardiotomy
2.17 / ☐ / Repair Heart Wound
2.18 / ☐ / Resection of Lump
2.19 / ☐ / Varicocele
2.20 / ☐ / Vesicotomy
2.21 / ☐ / Thorascopy
2.22 / ☐ / Video Assisted Thoracic Surgery
3.00 / Ears, Nose and Throat Surgery
3.01 / ☐ / Adenoidectomy
3.02 / ☐ / Excision Lesions, Local (Brachial, Thyroglossal Cysts, Polyps, etc.)
3.03 / ☐ / Major Lesions
3.04 / ☐ / Laryngectomy
3.05 / ☐ / Mastoidectomy, Simple
3.06 / ☐ / Mastoidectomy, Radical
3.07 / ☐ / Rhinoplasty
3.08 / ☐ / Sinus - Incision
3.09 / ☐ / Sinus - Excision (Submucous Resection)
3.10 / ☐ / Tonsillectomy
3.11 / ☐ / Otoscopy
3.12 / ☐ / Otoplasty
3.13 / ☐ / Tympanoplasty
3.14 / ☐ / Stapedectomy
3.15 / ☐ / Audio Meatoplasty
3.16 / ☐ / Otolaryngological Facial Nerve Surgery
3.17 / ☐ / Blepharoplasty
3.18 / ☐ / Rhytidectomy
3.19 / ☐ / Nasal and Nasal/Septal Reconstruction
3.20 / ☐ / Microtia & Traumatic Ear Defects
3.21 / ☐ / Eyelid Reconstruction
3.22 / ☐ / Radical Neck Dissection
3.23 / ☐ / Laryngectomy, Partial or Total
3.24 / ☐ / Functional Endoscopic Sinus Surgery
3.25 / ☐ / Myringotomy
3.26 / ☐ / Tracheotomy
3.27 / ☐ / Trauma and Repair of Blood Vessel Lacerations – Neck
3.28 / ☐ / Deep Abscess - Neck
3.29 / ☐ / Tracheal Reconstruction
4.00 / Maxillofacial and Oral Surgery
4.01 / ☐ / All Oral Surgery Including Excision of Lesions
4.02 / ☐ / Fractures Reduction
4.03 / ☐ / Tongue Tie Release
5.00 / Eye
5.01 / ☐ / Enucleation
5.02 / ☐ / Extraocular - Excision of Lesion (Pterygium, Nevus, etc.)
5.03 / ☐ / Removal of Foreign Body
5.04 / ☐ / Suture
5.05 / ☐ / Eyelid - Excision of Lesion (Chalazion, Xanthoma, etc.)
5.06 / ☐ / Plastic Repair of Eyelid
5.07 / ☐ / Orbit, Excision Lesion
5.08 / ☐ / Evisceration
5.09 / ☐ / Plastic Repair
5.10 / ☐ / Cataract, Glaucoma, Retinal Detachment; Intraocular Lens Implant
5.11 / ☐ / Intraocular & Extraocular Eye Surgery
5.12 / ☐ / Laser Procedures, Retinal
6.00 / Gynecological Surgery
(6) / 1.00 / ☐ / Amputation, Cervix
(6) / 1.01 / ☐ / Cauterization Cervix
(6) / 1.02 / ☐ / Closure - Rectovaginal Fistula
(6) / 1.03 / ☐ / Closure - Vesicovaginal Fistula
(6) / 1.06 / ☐ / Dilation and Curettage
(6) / 1.08 / ☐ / Excision of Glands (Bartholin’s, Skene’s)
(6) / 1.09 / ☐ / Hymenotomy
(6) / 1.10 / ☐ / Hysterectomy - Total
(6) / 1.11 / ☐ / Hysterectomy - Subtotal (Paracervical)
(6) / 1.12 / ☐ / Hysterectomy, Vaginal
(6) / 1.17 / ☐ / Repair - Cystocele
(6) / 1.19 / ☐ / Repair - Rectocele
(6) / 1.20 / ☐ / Salpingectomy (Ectopic Pregnancy)
(6) / 1.21 / ☐ / Salpingo-oophorectomy
(6) / 1.25 / ☐ / Abdominal Sterilization
(6) / 1.26 / ☐ / Hysteropexy
(6) / 1.28 / ☐ / Hysteroscopy
7.00 / Neurosurgery
7.01 / ☐ / Craniectomy
7.02 / ☐ / Craniotomy
7.03 / ☐ / Laminectomy
7.04 / ☐ / Neurotomy
7.05 / ☐ / Peripheral Nerve Surgery
7.06 / ☐ / Sympathectomy, Cervical
7.07 / ☐ / Sympathectomy, Lumbar
7.08 / ☐ / Sympathectomy, Thoracic
7.09 / ☐ / Carpal Tunnel Decompression
7.10 / ☐ / Stereotaxis Surgery on Brain
7.11 / ☐ / Percutaneous Cordotomy
7.12 / ☐ / Extracranial Carotid and Vertebral Surgery
7.13 / ☐ / Trans-Sphenoidal Surgery
7.14 / ☐ / Extracranial/Intracranial Bypass
7.15 / ☐ / Percutaneous Radiofrequency for Trigeminal Neuralgia
8.00 / Orthopedic Surgery
8.01 / ☐ / Amputations, Simple (Fingers, Toes)
8.02 / ☐ / Amputations, Major
8.03 / ☐ / Arthrodesis
8.04 / ☐ / Arthroplasty
8.05 / ☐ / Drainage, Bone
8.06 / ☐ / Graft, Bone
8.07 / ☐ / Reduction Dislocation or Fracture – Dislocation Closed
8.08 / ☐ / Dislocation Open with Suture
8.09 / ☐ / Dislocation Open with Metal Screw, Nail, Pin, Band, Plate, etc.
8.10 / ☐ / Repair Tendons - Primary
8.11 / ☐ / Repair Tendons - Secondary
8.12 / ☐ / Spinal Fusion
8.13 / ☐ / Tenotomy
8.14 / ☐ / Wounds Sufficient to Result in Permanent Disability or Death
8.15 / ☐ / Hip Replacement/Reconstruction
8.16 / ☐ / Arthroscopic Surgery
8.17 / ☐ / Laminectomy
8.18 / ☐ / The Ilizarov Method
8.19 / ☐ / Knee Anterior Cruciate Ligament
8.20 / ☐ / Radial Shortening Osteotomy Wrist
8.21 / ☐ / Graft, Skin
8.22 / ☐ / Lumbar Disc Replacement
9.00 / Rectal Surgery
9.01 / ☐ / Anal Fissure
9.02 / ☐ / Anal Fistula
9.03 / ☐ / Anoscopy, Proctoscopy, Sigmoidoscopy
9.04 / ☐ / Excision Lesion, Local
9.05 / ☐ / Excision Lesion, Malignant
9.06 / ☐ / Hemorrhoidectomy, Internal
9.07 / ☐ / Hemorrhoidectomy, External
9.08 / ☐ / Incision and Drainage
9.09 / ☐ / Pilonidal Cyst
9.10 / ☐ / Pull-through Operation for Hirschsprung's Disease in Imperforate Anus
9.11 / ☐ / Colectomy
10.00 / Urological Surgery
10.01 / ☐ / Adrenalectomy
10.02 / ☐ / Anterior Urethropexy
10.03 / ☐ / Augmentation Cecal Cystoplasty
10.04 / ☐ / Cavernosum
10.05 / ☐ / Circumcision
10.06 / ☐ / Continent Diversion with Colon Loop or Ileal Loop
10.07 / ☐ / Cutaneous Ureterostomy
10.08 / ☐ / Cystectomy
10.09 / ☐ / Cystolithotomy
10.10 / ☐ / Cystoscopy, Ureteroscopy
10.11 / ☐ / Cystostomy
10.12 / ☐ / Cystolithotripsy
10.13 / ☐ / Epididymectomy
10.14 / ☐ / Exploration of Testis
10.15 / ☐ / Hydrocele
10.16 / ☐ / Hydrocelectomy
10.17 / ☐ / Hypospadias Repair
10.18 / ☐ / Ileal & Colon Urinary Conduits
10.19 / ☐ / Ileal Loop
10.20 / ☐ / Insertion of Artificial Sphincter
10.21 / ☐ / Meatoplasty
10.22 / ☐ / Microscopic Vasovasotomy
10.23 / ☐ / Needle Bladder Suspension, Stamey Procedure, etc.
10.24 / ☐ / Nephrectomy, Donor
10.25 / ☐ / Nephrectomy, Harvest for Transplant
10.26 / ☐ / Nephrectomy, Partial
10.27 / ☐ / Nephrectomy, Total
10.28 / ☐ / Nephrectomy, Transplant
10.29 / ☐ / Nephrolithotomy
10.30 / ☐ / Nephroureterectomy
10.31 / ☐ / Orchidectomy
10.32 / ☐ / Orchiopexy
10.33 / ☐ / Percutaneous Nephrolithotomy
10.34 / ☐ / Percutaneous Nephrolithotripsy
10.35 / ☐ / Penile Insert
10.36 / ☐ / Penile Prosthesis Insertion
10.37 / ☐ / Plastic Operations on Kidney
10.38 / ☐ / Plastic Surgery of Penis
10.39 / ☐ / Prostatectomy
10.40 / ☐ / Pyeloplasty
10.41 / ☐ / Radical Prostatectomy
10.42 / ☐ / Renal Autotransplantation
10.43 / ☐ / Renal Trauma & Repair of Lacerations
10.44 / ☐ / Renal Vascular Surgery
10.45 / ☐ / Retroperitoneal & Pelvic Lymphadenectomy
10.46 / ☐ / Revascularization of the Corpora
10.47 / ☐ / Spermatocelectomy
10.48 / ☐ / Testicular Autotransplantation
10.49 / ☐ / Thoracoabdominal Approach to the Adrenal Gland/Kidney
10.50 / ☐ / Total & Partial Adrenalectomy
10.51 / ☐ / Total Cystectomy
10.52 / ☐ / Transurethral Resection
10.53 / ☐ / Ureteroscopy
10.54 / ☐ / Ureterolithotomy
10.55 / ☐ / Ureterolithotripsy
10.56 / ☐ / Urethral Surgery
10.57 / ☐ / Urethrectomy
10.58 / ☐ / Urethrotomy, External
10.59 / ☐ / Urethrotomy, Internal
10.60 / ☐ / Varicocele/Varicocelectomy
10.61 / ☐ / Vesicotomy
10.62 / ☐ / Vasectomy
10.63 / ☐ / Ureterectomy
10.64 / ☐ / Renal Cyst Drainage
10.65 / ☐ / ESWL
10.66 / ☐ / Vasectomy Reversal
10.67 / ☐ / Prostatic Seeding Procedure
11.00 / Other Procedures
11.01 / ☐ / Reimplantation
11.02 / ☐ / Free Tissue Transfer
11.03 / ☐ / Translumbar Aortography
11.04 / ☐ / Peripheral Vascular System Operative Procedures
11.05 / ☐ / Femoral Arteriography
11.06 / ☐ / Brachial Arteriography
11.07 / ☐ / Angiography
11.08 / ☐ / Venogram
11.09 / ☐ / Microvascular Tissue Transplant
11.10 / ☐ / Implantation Alloplastic Material; Soft Tissue & Bone
11.11 / ☐ / Head and Neck Reconstruction
11.12 / ☐ / Repair of Congenital Deformities
11.13 / ☐ / Reconstruction of Scalp, Forehead, Calvaria
11.14 / ☐ / Cosmetic Surgery of the Aging Face
11.15 / ☐ / Abdominoplasty
11.16 / ☐ / Suction Assisted Lipectomy
11.17 / ☐ / Orbital Exenteration for Malignancy
11.18 / ☐ / Pelvic Exenterations (Total, Anterior, Posterior)
11.19 / ☐ / Hemipelvectomy & Forequarter Amputation
11.20 / ☐ / Infusaid Pump, Hepatic Artery Cath for Long Term Chemo
11.21 / ☐ / Chemical Peeling
11.22 / ☐ / Microsurgery
11.23 / ☐ / Liposuction of the Abdomen, Thighs, and Hips Only
11.24 / ☐ / Excision of Superficial Cutaneous Lesions Anywhere on the Body
11.25 / ☐ / Muscle Flap Harvesting
11.26 / ☐ / Deep Abscess (Pelvic, etc.)
11.27 / ☐ / Endovascular Deployment of Aortic Grafts for Treatment of Abdominal Aortic Aneurysm
11.28 / ☐ / Septoplasty
13.00 / ☐ / CRITICAL CARE MANAGEMENT (includes Bronchoscopy, Laryngoscopy, Ventilator Care, TPN, etc.)
Special Privileges *
(12) / 1.00 / ☐ / Culdoscopy
(12) / 1.01 / ☐ / Gastroscopy
(12) / 1.02 / ☐ / Peritoneoscopy
(12) / 1.03 / ☐ / Bronchoscopy
(12) / 1.04 / ☐ / Laryngoscopy (Flexible/Rigid)
(12) / 1.05 / ☐ / Tracheoscopy
(12) / 1.06 / ☐ / Sigmoid, Flexible Diagnostic
(12) / 1.07 / ☐ / Sigmoid, Rigid Diagnostic
(12) / 1.08 / ☐ / Laparoscopy
(12) / 1.09 / ☐ / Colonoscopy
(12) / 1.10 / ☐ / GI Endoscopy with Gen. Anesthesia
(12) / 1.11 / ☐ / Colonoscopy with Polypectomy
(12) / 1.12 / ☐ / Sigmoid, Flexible With Biopsy and Polypectomy
(12) / 1.13 / ☐ / Sigmoid, Rigid With Biopsy and Polypectomy
(12) / 1.14 / ☐ / Laparoscopic Cholecystectomy
(12) / 1.15 / ☐ / Laparoscopic Appendectomy
(12) / 1.16 / ☐ / Laparoscopic Hysterectomy
(12) / 1.17 / ☐ / Laparoscopic Lysis of Adhesions
(12) / 1.18 / ☐ / Laparoscopic Exam. of Abdominal Cavity/Common Duct Exploration
(12) / 1.19 / ☐ / Laparoscopic Inguinal Herniorrhaphy
(12) / 1.20 / ☐ / Laparoscopic Suturing Techniques
(12) / 1.23 / ☐ / Laparoscopic Bowel/Hernia Repair
(12) / 1.24 / ☐ / Laparoscopic Stapling
(12) / 1.25 / ☐ / Laparoscopic Inguinal Hernia Repair
(12) / 2.00 / ☐ / TPN/PPN*
(12) / 3.00 / ☐ / Yag Laser*
(12) / 3.01 / ☐ / CO 2 Laser*
(12) / 3.02 / ☐ / Colposcopy
(12) / 3.03 / ☐ / Anoscopy
(12) / 3.04 / ☐ / Proctoscopy
(12) / 3.05 / ☐ / Midas Rex Bone Scalpel
(12) / 3.06 / ☐ / Esophagoscopy
(12) / 3.07 / ☐ / Myelogram
(12) / 3.08 / ☐ / Admin. of IV Anesthesia/Analgesia When Loss of Reflex May Occur
(12) / 3.09 / ☐ / Lithotripsy
(12) / 3.10 / ☐ / Endoscopic Carpal Tunnel Release
(12) / 3.11 / ☐ / Automated Percutaneous Lumbar Discectomy
(12) / 3.12 / ☐ / Arteriovenous Fistula for Renal Access