Healthcare Telerad Privileges Form

HEALTHCARE TELERAD PRIVILEGES FORM

Purpose: Use this form to request remote teleradiology privileges for interpretation and reporting of diagnostic imaging studies. Completion of this form and submission of required supporting documentation constitutes an application for privileges; approval is contingent on review of credentials, privileges already held at primary facility, and adherence to institutional policies and applicable law.

Applicant Information

Professional Licensure and Insurance

License expiration date:

Policy number:    Coverage expiration:

Privileges Requested (check all that apply)

Preliminary interpretations (provisional reporting)
Final report and sign-out authority
Consultative reads (no sign-out)
Neuroradiology (CT/MR brain/spine)
Body CT/MRI
Pediatric radiology
Mammography (requires facility credentialing for mammography)
Ultrasound
Nuclear medicine/ PET interpretation
Other:

Technical Access & Operational Requirements

Requested system access (check all that apply):
PACS image viewing
PACS reporting module / structured report entry
RIS scheduling / order reconciliation
Electronic health record access for reports and clinical data
Remote proctoring / peer review access

Desired access level:

Attestations, Conditions and Agreement

By submitting this application I certify under penalty of perjury that the information provided on this form and in any supporting documentation is true, accurate and complete to the best of my knowledge. I agree to comply with all institutional policies and procedures applicable to teleradiology services, including but not limited to confidentiality, information security, mandatory reporting, quality assurance, and incident reporting requirements.

I acknowledge that remote interpretation is subject to technical limitations and that the institution may impose restrictions on scope of practice, case types, or patient populations. Approval of privileges does not alter or replace liability or malpractice obligations; I will maintain current licensure and malpractice insurance as required and will provide evidence upon request. I consent to monitoring and audit of my remote reading activity and to provision of my performance data to relevant privileging committees.

I understand that privileges may be suspended or revoked for cause, including but not limited to failure to comply with policies, loss of licensure or insurance, substandard performance, or security breaches. The institution retains the right to impose proctoring, additional training, or specific conditions as a condition of continued privileges.

By applying for teleradiology privileges I authorize the institution to grant me access to patient data and images as necessary to perform approved interpretation services. I acknowledge my obligation to limit access to the minimum necessary information and to safeguard patient confidentiality in accordance with applicable law and institutional policy.

Required Supporting Documents (attach to application)

Indicate included documents:
Current curriculum vitae
Copy of current state medical license
Board certificate or board-eligible documentation
Malpractice declarations / insurance binder
Current facility privileges / privileging letter
Other:

Administrative Use Only

Applicant Certification and Signature

I certify that I have read and understand the conditions, attestations, and responsibilities set forth in this application. I agree to notify the institution promptly of any change in my licensure, malpractice coverage, disciplinary status, or ability to meet the technical and professional requirements for teleradiology privileges.

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