Application for Clinical Privileges – Cardiology
Applicant Name: _____________________________________________________
Staff Category: _______________________________________ Specialty: ______________________________________
Effective from _______/_______/_______ to _______/_______/_______
Request all privileges desired by checking the applicable requested box.
Request Not Requested Granted Not Granted
Evaluate, diagnose, treat, medically manage and provide consultation to
adolescent and adult patients who present with acute or chronic heart
disease and who may require invasive diagnostic procedures. May
provide care to patients in the intensive care setting in conformance with
unit policies. Assess, stabilize, and determine disposition of patients with
emergent conditions consistent with medical staff policy regarding
emergency and consultative call services. The privileges in this specialty
include the procedures on the attached procedures list and such other
procedures that are extensions of the same techniques and skills.
Admit patients to the appropriate level of care.
Procedures: Remove those procedures not within
capabilities and capacities of Hospital
Arterial catheter insertion
Insertion of central venous catheter
Elective cardioversion
Electrocardiogram (EKG) interpretation including ambulatory monitoring
Transthoracic echocardiography
Stress testing: exercise and pharmacologic
Nuclear cardiology
Pericardiocentesis
Carotid ultrasound interpretation
Insertion of temporary pacemaker
Moderate Sedation: Remove this privilege not within
capabilities and capacities of Hospital
Moderate/Conscious Sedation
Other Privileges Desired (Not Listed Above)
1
Applicant Name: _____________________________________________________
Staff Category: _______________________________________ Specialty: ______________________________________
Effective from _______/_______/_______ to _______/_______/_______
Signature of Applicant:
I have requested only those privileges for which by education, training, current experience, and demonstrated competency I
am entitled to perform and that I wish to exercise at (Insert Name of Hospital).
I also understand that by making this request I am bound by the applicable Medical Staff Bylaws and/or policies of (Insert
Name of Hospital). I also attest that my professional liability insurance covers the privileges I have requested.
I understand that it is my responsibility to provide (Insert Name of Hospital) with documentation of my education, training,
current experience and information regarding the number of services and procedures I have performed in order to assist the
Medical Staff in the determination of competency or continued competency.
I affirm that I will obtain a consultation with a qualified medical staff member when it is in the best interest of the patient
and/or when my expertise does not meet the clinical needs of the patient.
Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions
are governed by the applicable section of the Medical Staff Bylaws and related documents.
________________________________________________________ _______________________________
Signature of Applicant Date
Medical Staff/Credentials Committee Recommendations – Privileges
I/we have reviewed the requested clinical privileges and supporting documentation and make the following
recommendation(s): Please check the applicable box(es)
Recommend all requested privileges
Do not recommend any of the requested privileges
Recommend privileges with the following conditions/modifications/deletions (listed below)
Privilege Conditions/Modification/Deletion/Explanation
________________________________________________ ________________________________________
Medical Staff/Credentials Committee Date
Board of Directors Determination
2
Applicant Name: _____________________________________________________
Staff Category: _______________________________________ Specialty: ______________________________________
Effective from _______/_______/_______ to _______/_______/_______
I/we have reviewed the requested clinical privileges and supporting documentation and make the following determination(s):
Please check the applicable box(es).
Approve all requested privileges
Approve none of the requested privileges
Approve the following privileges with the following conditions/modifications/deletions (listed below)
Privilege Conditions/Modification/Deletion/Explanation
_______________________________________________ ________________________________________
Board of Directors Date
Hospital Name
Form Approved By:
Medical Staff: _______________________
Date
Board of Directors: ____________________
Date
