To Be Eligible to Request Clinical Privileges, the Following Threshold Criteria Must Be Met

UNIVERSITY HOSPITAL-MCDUFFIE

NEUROLOGY

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 residency training program in Internal Medicine. Successful

completion of an approved residency/fellowship in Neurology. Applicant mustmeet 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 Internal Medical residency program and residency/fellowship program

in Neurologyor current competency inproviding medical management and/or treatment to patients within

the scope of core privileges for Neurology. Adequate documentation of this performance requires submission

of a case list and a referenceletter. All initial applicants at completion of residency and/or fellowship must

provide an official caselist 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 fromthe 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 patients
Evaluation, diagnosis and medical treatment of patients with disorders of the central and peripheral nervous system. These privileges include the provision of consultation as well as the ordering of diagnostic studies and procedures.
Electroencephalography and Evoked Potential studies
Lumbar Puncture

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 University Hospital McDuffie.

SPECIAL PRIVILEGES to include: REQUESTEDGRANTED

Electromyography
Neurosonography
Injection of botox for movement disorders
Moderate Sedation
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 SignatureDate