Application for Clinical Privileges – Dermatology
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, and provide consultation to patients of all ages,
with benign and malignant disorders of the skin, mouth, external genitalia,
hair, and nails, as well as sexually transmitted diseases. Includes the
diagnosis and treatment of skin cancers, melanomas, moles, and other
tumors of the skin, management of contact dermatitis and other allergic
and nonallergic skin disorders, cosmetic disorders of the skin such as hair
loss and scars, the skin changes associated with aging, and recognition of
skin manifestations of systemic and infectious diseases. Assess, stabilize,
and determine the disposition of patients with emergent conditions
consistent with medical staff policy regarding emergency and consultative
call services
Admit patients to the appropriate level of care
Procedure: Remove those procedures not within the
capabilities and capacities of Hospital
Botulinum toxin injection
Chemical face peels
Collagen injections
Cryosurgery
Destruction of benign and malignant tumors
Electrosurgery
Excision of benign and malignant tumors with simple, intermediate and
complex repair techniques including flaps and grafts
Intralesional injections
Patch tests
Photomedicine, phototherapy and topical/system pharmacotherapy
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
2
Applicant Name: _____________________________________________________
Staff Category: _______________________________________ Specialty: ______________________________________
Effective from _______/_______/_______ to _______/_______/_______
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
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
3
Applicant Name: _____________________________________________________
Staff Category: _______________________________________ Specialty: ______________________________________
Effective from _______/_______/_______ to _______/_______/_______
Board of Directors: ____________________
Date
