Healthcare Diagnostic Privileges Form

Healthcare Diagnostic Privileges Form

This form is an application for clinical diagnostic privileges within the facility and authorizes verification of professional credentials, training, experience, competence, and other information necessary to the privileging process. Completion and signature by the applicant constitute certification that the information provided is true and complete to the best of the applicant's knowledge and that false statements may result in denial, limitation or revocation of privileges and may be reported to appropriate licensure and accreditation bodies.

Applicant Information

Date of Birth:    Gender:

Licensure, Certification and Professional ID

State of License:    License Expiration:

Requested Diagnostic Privileges

Check each category of diagnostic privileges requested and indicate level of privilege sought. Privileges granted will be based on documented training, experience, demonstrated competence, and applicable facility bylaws and policies.

Radiology interpretation (plain film, CT, MRI)    Level:

Electrocardiogram (ECG/EKG) interpretation    Level:

Pulmonary function testing interpretation    Level:

Laboratory test ordering and interpretation    Level:

Nuclear medicine interpretation    Level:

Training, Experience and Supporting Documentation

Provide the most recent evidence of training and competence. Attach or list documents below. The facility may require submission of primary source verification and additional documentation as part of the privileging review.

Board certificate    CME certificates    Training/proctoring letters

Professional Liability Insurance

Policy Expiration Date:

Professional History and Disciplinary Questions

Have you ever had professional licensure, certification or hospital privileges denied, revoked, suspended, restricted, investigated or subject to probation?   Yes   No

Have you ever had a malpractice claim filed against you or settled a malpractice claim?   Yes   No

References

Provide three professional references familiar with your diagnostic competence.

Competency, Proctoring and Monitoring

The facility may require initial proctoring and ongoing performance monitoring for the granted diagnostic privileges. Specify requested proctoring arrangements or prior proctoring evidence.

Privacy and Authorization

I acknowledge that information provided in this application is subject to verification and that the facility may obtain primary source verification of credentials, education, training, professional references, malpractice history and other relevant information. I authorize third parties to release information necessary to assess my qualifications, and I release such parties from liability for furnishing information in good faith.

I understand privileges, if granted, are subject to all applicable facility bylaws, rules, regulations, policies and procedures, and may be revoked, limited or suspended based on clinical performance, disciplinary action or changes in status. I certify that I will comply with applicable privacy and confidentiality standards when exercising diagnostic privileges.

Authorization Expiration Date:

By checking this box I acknowledge receipt of and agreement to comply with the facility's privacy practices and clarifications regarding protected health information disclosure for privileging and quality assurance functions.

Applicant Certification and Attestation

I hereby certify under penalty of perjury that the information provided on this application and all supporting documentation is true, complete and correct. I understand that omission or misstatement of material facts may be grounds for denial, revocation or limitation of privileges and may be reported to licensing authorities. I consent to the release of information contained in this application to persons and organizations involved in the evaluation process.

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