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Delineation of Clinical Privileges

Clinical privileging defines the scope and limits of practice for individual providers. Privileges are based on evaluation of the individual’s credentials and performance. Information on this form may be released to professional organizations if needed to license or monitor professional standards of health care providers. 

Policy and Procedure Manual by the Kalihi-Palama Health Center

Sample credentialing policy (see Human Resources for other credentailing resources).
Checklist of delineation of privileges for OB/GYN care for applicants or new hires.
Checklist of clinical social worker privileges for use with any applicants or new hires.
Checklist of registered dietician privileges for use with any applicants or new hires.
Comprehensive Health Center guidelines for privileging, credentialing and appointments.
Health Center credentialing and priviliging policy statement.
Sample policy on employee TB skin testing.
Outline of scope of medical practice guidelines.
The intent of this privilege list is to aid in evaluating the abilities and training of applicants and as a general guide to the level of functioning of that provider.
The initial credentialing process must include primary source verification of graduation from an accredited professional school and residency training program and a query of the National Practitioner Data Bank. This outlines the policy and provides a release of information form.
Checklist of requirements for any practitioner reappointment. Recommended that it be filled out every two years following initial appointment.
Checklist that outlines requirements for any physician’s initial appointment to the health center.
Checklist of Delineation of Privileges in Family Practice Ambulatory Care for applicants or new hires.
Checklist of Primary Care Practitioner privileges in ambulatory care for use with any applicants or new hires.
This form should be filled out annually by any clinical subcontractors. It outlines licensing, appointment certification and credentialing for any clinical staff that provides services under the subcontract.
Clinical Assistant privileging request form for lab procedures related to In-House Lab Tests and Microscope Use.
Clinical Assistant privileging request form related to nursing abilities, patient well-being, and IVs.
This document outlines the process a health center goes through to appoint a new clinician to staff.
Sample written policy for clinician appeals and hearings related to privileging and appointment.
Checklist of delineation of privileges for either dentists or dental hygenists for applicants or new hires.

Request for Additional Privilege
Licensed Independent Practitioner

Application for Clinical Privileges
Physician
Specialty: Family Medicine

Application for Clinical Privileges Physician Specialty: Dentistry