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Notice of Privacy Practices

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MIDLAND MEMORIAL HOSPITAL
Delineation of Privileges
INTERVENTIONAL CARDIOLOGY

Your home for healthcare

Policy Tech Ref #: 5059

Date Approved:

Last Review Date:

Physician Name:

Interventional Cardiology Core Privileges

Qualifications

Minimum threshold criteria for granting core privileges in interventional cardiology:

• Basic education: MD or DO

• Minimum formal training: Applicants must be able to demonstrate successful completion of an ACGME- or AOA-accredited training program in interventional cardiology or equivalent practice experience if training occurred prior to 2003.

AND/OR

• Applicants must also hold subspecialty certification in interventional cardiology by the ABIM or complete a certificate of added qualification in interventional cardiology by the AOBIM. (*Members of the Staff prior to the adoption of Bylaws 10/2007 are considered grandfathered in and are encouraged but not required to achieve board certification).

Required current experience:

• Applicants must be able to demonstrate that they have performed at least 25 percutaneous coronary intervention procedures, reflective of the scope of privileges requested, in the past 12 months or successful completion of an ACGME or AOA residency or clinical fellowship within the past 12 months.

References for New Applicants

If the applicant is recently trained, a letter of reference should come from the director of the applicant’s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced.

Reappointment

Reappointment should be based on unbiased, objective results of care according to the organization’s existing quality improvement measures. To be eligible to renew privileges in interventional cardiology, the applicant must have current demonstrated competence and an adequate volume of experience (50 percutaneous coronary intervention procedures) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Please check requested privileges.

Requested

Approved

Not Approved

Core privileges include but are not limited to:

Core Privileges:

Core privileges in interventional cardiology include the ability to admit, evaluate, treat, and provide consultation to adolescent and adult patients by use of specialized imaging and other diagnostic techniques to evaluate blood flow and pressure in the coronary arteries and chambers of the heart, as well as technical procedures and medications to treat abnormalities that impair the function of the cardiovascular system. Physicians may provide care to patients in the intensive care setting in conformity with unit policies. Privileges also include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

• Intracoronary infusion of pharmacological agents, including thrombolytics and vasoactive agents for epicardial and microvascular spasm

• Use of intracoronary Doppler and flow wire

• Percutanenous coronary intervention includes any of the following procedures: femoral, brachial, or radial axillary cannulation for diagnostic angiography; interpretation of coronary arteriograms, ventriculography, and hemodynamics

• Intracoronary foreign body retrievalus access catheters

• Intracoronary mechanical thrombectomy

• Intracoronary stents

• Intravascular ultrasound of coronaries

• Management of mechanical complications of percutaneous intervention

• Performance of balloon angioplasty, stents, and other commonly used interventional devices

• Percutaneous coronary atherectomy

Requested

Approved

Not Approved

Criteria

Refer-and-follow privileges

Privileges include performing outpatient preadmission history and physical, ordering noninvasive outpatient diagnostic tests and services, visiting patients in the hospital, reviewing medical records, consulting with the attending physician, and observing diagnostic or surgical procedures with the approval of the attending physician or surgeon.

Requested

Approved

Not Approved

Procedure Criteria

Non-Core Privileges

For each special request, threshold criteria (i.e., additional training or completion of a recognized course and required experience) must be established. Special requests for interventional cardiology include.

Percutanenous peripheral vascular interventions to include diagnostic and therapeutic angiography, angioplasty, and stenting – arterial, venous systems, grafts and fistulas.

New Applicant: Demonstrated current competence and experience of the performance of at least 25 percutaneous peripheral vascular interventions in the past 12 months or must have trained in an accredited program and provide proof of accredited program training.

Reappointment: Demonstrated current competence and experience of the performance of at least a total of 50 diagnostic and/or interventional cases in the past 24 months or must have trained in an accredited program and provide proof of accredited program training.

Implantation of cardiac electronic devices, including permanent pacemakers and ICDs

New Applicant: Demonstrated current competence and experience of the performance of at least 25 implantation of cardiac electronic devices in the past 12 months or completion of training in the past 12 months.

Reappointment: Demonstrated current competence and experience of the performance of at least 50 implantation of cardiac electronic devices in the past 24 months or completion of training in the past 24 months.

Moderate Sedation

Meet the criteria set forth by the Rules and Regulations for Anesthesia Services and complete “Requirements for Moderate Sedation Privileges” form.

Requested

Approved

Not Approved

Privilege/Criteria

Current Privileges:

List any current privileges not listed above in core or non-core. These privileges will remain in effect until the end of the current appointment period and then will be moved up to the appropriate core/non-core section.

Please provide criteria and supporting documentation to medical staff office for any non-core privileges listed.

Core

Non-Core

To the applicant: If you wish to exclude any privileges, please strike through the privileges that you do not wish to request and then initial.

I understand that by making this request, I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at Midland Memorial Hospital. I also acknowledge that my professional malpractice insurance extends to all privileges I have requested and I understand that:

(a) In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

(b) Applicants have the burden of producing information deemed adequate by Midland Memorial Hospital for a proper evaluation of current competence, other qualifications and for resolving any doubts.

(c) I will request consultation if a patient needs service beyond my expertise.

Physician’s Signature/Printed Name Date

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and:

Recommend all requested privileges

Recommend privileges with the following conditions/modifications:

Do not recommend the following requested privileges:

Privilege Condition/modification/explanation

Notes:

Department Chair/Chief Signature

Date

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What the Notice of Privacy Practices Is

The Notice of Privacy Practices explains how a covered entity may use and disclose an individual's protected health information (PHI), and it describes patients' rights regarding that information under the HIPAA Privacy Rule (45 CFR §164.520). It summarizes permitted uses and disclosures, required safeguards, complaint procedures, and the right to access, amend, and request restrictions on PHI. Covered entities and qualified health plans must make the notice available to patients at first service and upon request, and must post it where services are provided and on any website offering direct patient services.

Why a Clear Notice Matters

A clear Notice of Privacy Practices helps patients understand rights over their PHI, supports regulatory compliance with HIPAA (45 CFR §164.520), and documents an entity's privacy policies. It reduces complaints, streamlines requests for access or amendment, and provides legal transparency.

Why a Clear Notice Matters

Who Issues and Uses the Notice

Covered entities and health plans use this Notice to meet HIPAA disclosure obligations and to inform patients how their PHI is handled.

  • Hospitals and clinics: Issue at first service and include in patient intake materials.
  • Health plans: Send to enrollees and make available online and upon request.
  • Business associates: Provide to covered entity patients when required by contract or law.

If you administer patient communications, maintain a current Notice, track distribution, and document patient acknowledgements for compliance records.

Core elements every Notice should include

A professional Notice of Privacy Practices clearly states permitted uses, patient rights, contact information, complaint procedures, effective date, and how PHI is protected.

Uses and Disclosures

Describe routine uses (treatment, payment, operations), incidental disclosures, and any disclosure categories requiring authorization; be specific about third-party sharing and research or marketing exceptions under HIPAA.

Patient Rights

Explain right to access and obtain copies, request amendment, accounting of disclosures, right to request restrictions, and right to receive confidential communications.

Privacy Practices Contact

Provide a named privacy official, phone number, mailing address, and email contact for submitting complaints or requests related to PHI access or privacy concerns.

Complaint Process

Describe how to file a complaint internally and note the right to file with HHS OCR; include timeframe expectations for acknowledgements and responses.

Effective Date

State the notice effective date and advise patients that the entity will update the Notice; explain how revised notices will be posted and distributed.

Special Situations

Identify situations like fundraising, public health reporting, or health plan communications; disclose any state-law stronger protections that affect PHI handling.

Legal and security foundations to reference

HIPAA Basis: 45 CFR §164.520 (Privacy Rule)
State Privacy Laws: Varies by state; may be stronger
BAA Requirement: Business Associate Agreement may be required
Consent Exceptions: Required for most psychotherapy notes
Access Rights: Right to inspect and obtain copies
Amendments: Right to request changes to PHI

Step-by-step: preparing and issuing the Notice

Follow these steps to create, approve, and distribute a compliant Notice of Privacy Practices to patients and staff.

  • 01
    Draft content: Compile accurate descriptions of uses, rights, contacts.
  • 02
    Legal review: Have counsel review for HIPAA/state compliance.
  • 03
    Approve and date: Set effective date and document approval.
  • 04
    Distribute: Post, provide at first visit, and publish online.

Where to file, send, or post the Notice

Identify recipients and posting locations for the Notice, and define how to record delivery or patient acknowledgement.

  • Patients: Give at first service and on request.
  • Website: Post full Notice on patient-facing website.
  • Intake materials: Include a paper copy in registration packets.
  • OCR complaints: Provide HHS OCR contact info for complaints.

Technical considerations for electronic distribution

Digital delivery requires PDF/HTML formats, secure hosting, ADA accessibility, clear download options, and visible posting on the provider website.

  • Formats: PDF and HTML recommended.
  • Accessibility: WCAG 2.0 AA compliance advised.
  • Retention: Maintain copy in records per policy.

Digital workflow settings to capture acknowledgements

Configure digital workflows to capture acknowledgements, timestamp delivery, and store signed receipts in the patient record.

Field Configuration
Delivery Method Email link, portal, paper
Acknowledgement Signed form or electronic consent log
Storage Attach PDF to EHR or document repository
Access Control Role-based access, audit trail enabled

Penalties and compliance risks to avoid

OCR Enforcement: Civil penalties and corrective action
Patient Complaints: Increased complaints and investigations
Reputational Harm: Public loss of trust and credibility
State Liability: State-level enforcement or private actions
Operational Burden: Increased audits and remediation costs
Contract Risk: Business associate breaches can create liability

Common mistakes when preparing the Notice

  • Using overly technical or legalistic language that patients cannot understand and that increases phone inquiries and confusion.
  • Failing to update the effective date or version history when privacy practices change, which can create compliance gaps during audits.
  • Omitting a named contact or providing incorrect contact information, preventing patients from filing complaints or submitting access requests.
  • Distributing inconsistent copies (printed version differs from website version), which can trigger regulatory scrutiny and patient disputes.

Timelines and timing obligations to keep in mind

Key timing rules focus on initial delivery, posting online, and retention; ensure processes assign responsibilities and document each timing event.

Initial Delivery:

Provide at first service and upon request (45 CFR §164.520).

Revisions:

Post updated Notice promptly after revision and provide to new patients.

Patient Requests:

Acknowledge access or amendment requests per HIPAA timeframes.

Website Posting:

Keep online copy current and accessible to patients.

Record Retention:

Maintain Notice versions and acknowledgements for six years (45 CFR §164.530(j)).

eSignature vendor comparison for distributing and signing the Notice

Feature-level comparison of common eSignature vendors for distributing and signing a Notice of Privacy Practices; signNow is listed first per platform data.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

FAQs — common questions about the Notice of Privacy Practices

Answers to frequently asked questions about delivery, signatures, updates, and interactions between federal and state rules for the Notice of Privacy Practices.


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