UC Davis, Student Health and Counseling Services 180-02 Appointment & Reappointment/AHP

Attachment 5

OPTOMETRIST

PRIVILEGE DELINEATION FORM

This privilege form describes the qualifications related to competency to exercise the defined clinical privileges that may be requested by a qualified practitioner based on the training and experience required. Privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, staff, and other support required to provide the services defined in this document. The applicant must also adhere to any additional organizational, regulatory, or accrediting requirements that this facility is obligated to meet.

NAME:

(Please Print)

Instructions: Please check off the “Requested” box for all privileges requested. If you wish to exclude any procedures, please strikethrough, initial and date those procedures that you DO NOT wish to request.

Request / Requested Privileges / Initial Criteria / Renewal Criteria / Proctor Requirements
q / CORE PRIVILEGES
1.  Comprehensive evaluation of the eye and its adnexa, diagnosis, and treatment of visual disorders and anomalies.
2.  General and ophthalmic medical history
3.  Visual acuity evaluation
4.  Lensometry
5.  Measurements, e.g., pupillary distance, near point of convergence, exophthalmos, and accommodation
6.  Ocular motility evaluations
7.  Stereopsis and depth perception evaluation
8.  Evaluation of pupillary reflexes
9.  Color vision assessment
10.  Evaluation of binocular function
11.  Spectacle prescribing
12.  Contact lens fitting, prescription, follow-up care and modifications
13.  Pupil dilation
14.  Examination of the eye using slit lamp biomicroscopy and goniolens
15.  Fundus examination of the peripheral retina using indirect ophthalmoscopy (with scleral depression when necessary) and fundus lenses
16.  Diagnosis, treatment with topically applied medications, and management of diseases and conditions of the eye and adnexa
17.  Conduct and interpret visual field tests
18.  Refractions, manifest and cycloplegic
19.  Tonometry, contact and non-contact / ·  Graduation from an accredited Optometry Program with a Doctor of Optometry degree; AND
·  Active and Current License with the CA Board of Optometry / ·  Minimum of fifteen (15) cases as evidenced by the facility EHR in the prior three (3) years. / ·  Five (5) chart reviews.

I certify that I have had the necessary training and experience to perform the procedures that

I have requested. The burden of producing information deemed adequate by the organization for

a proper evaluation of current competence, current clinical activity and other qualifications and

for resolving any doubts related to qualifications for the requested privileges is mine. I have reviewed

all the criteria that pertain to those privileges that I am requesting and I certify that I meet those criteria.

In exercising the privileges granted to me, I agree to strictly abide by the facility’s Credentialing

Policies and Procedures.

Applicant’s name: Signature and Print / Date

RECOMMENDATIONS/APPROVAL

I have reviewed the applicant’s credentials, experience, training, health status, current competence and peer recommendations relative to this request for privileges. The following recommendations are made:

Supervisor ______Date ___/____/____ o RECOMMENDED

Medical Director______Date ___/____/____ o RECOMMENDED

Peer Review Chair______Date ___/____/____ o RECOMMENDED

Executive Director ______Date ___/____/____ o APPROVED oDENIED o DEFERRED

Privileges Effective: From ___/____/____ to ___/____/____ (not to exceed appointment date)

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