UNIVERSITYHOSPITAL
DEPARTMENT OF FAMILY PRACTICE
REQUEST FOR PRIVILEGES
To be eligible to request clinical privileges, the following threshold criteria must be met.
EDUCATION:MD or DO
TRAINING:
Successful completion of an approved three year residency training program in Family Practice
Of hold active medical staff privileges for more than ten years. Applicant must meet the
requirements for board certification outlined in the Medical Staff Bylaws.
EXPERIENCE:
The initial applicant must be able to demonstrate training and/or experience on a level commensurate with
specialty training from an accredited family practice residency program or current competency inproviding
medical management and/or treatment to patients within the scope of core privileges for Family Practice.
Adequate documentation of this performance requires submission of a case list and a reference
letter. All initial applicants at completion of residency and/or fellowship must provide an official case
list and letter of recommendation assessing performance from the Residency and/or Fellowship Program
Director. Allinitial applicants beyond 12 months of residency completion must provide a case list from
the hospitalwhere the applicant has been actively practicing for the last year and a letter of
recommendationassessing performance from the hospital’s Chief of Staff or Department Chair.
The reappointment applicant must demonstratecontinuing competence and meet requirements for C.M.E.
according to the Medical Staff Bylaws.Reappointment is based upon unbiased, objective review of result
of care according to thehospital’s existing quality mechanisms.
CORE PRIVILEGES:
(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing
list but rather reflective of the categories/types of privileges included in the core.)
REQUESTED GRANTED
Admission of patientsMedicine
Evaluation, diagnosis, management and treatment of non-surgical adult patients without life-threatening complications presenting to the medicine services. Consultation required for patients in intensive care with continuity of care assured to the family physician.
Minor Surgery Procedures
Suturing uncomplicated lacerations
I&D abscess
Simple skin biopsy or excision
Treating uncomplicated minor closed fractures and uncomplicated
dislocations
Pediatrics
Admission of children 3 years of age or greater (Patients under the age of
2, requiring admission for medical conditions, must be admitted by a
Pediatrician. Admission of those patients age 2-3 require pediatric
consultation.
Circumcision
Peripheral venous cutdowns
Intubation
Laceration repair
Drainage of superficial abscesses
Diagnostic: lumbar punctures
Diagnostic: laryngoscopy
DEPARTMENT OF FAMILY PRACTICE
REQUEST FOR PRIVILEGES
PAGE 2
Applicants requesting any other special privileges listed below must present documentation oftraining in
each privilege requested with a letter from the training director attesting to theapplicant’s competence
and/or must meet any additional/other credentialing criteria which hasbeen approved by the Medical Staff
and the Governing Board of UniversityHospital.
SPECIAL PRIVILEGES to include: REQUESTED GRANTED
Invasive ProceduresIncision and drainage of abscess
Lumbar punctures
Thoracentesis
Flexible sigmoidoscopy
Rigid sigmoidoscopy
Arterial cannulation
Debridement of superficial ulcers
Paracentesis
The applicant is required to submit a separate letter of
request for any privilege not included on this form.
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Applicant’s SignatureDate7/07