Albuquerque Area
DENTISTRY PRIVILEGE REQUEST FORM
PROVIDER NAME:
____________________________________
Initial Privileging
SERVICE UNIT:
______
Re-privileging/reappointment
Minimum Thresholds
In order to be eligible to request clinical privilege in Dentistry, a practitioner must meet the following minimum
threshold criteria:
 Education: DDS or DMD
 Required previous experience: Must be able to demonstrate that he/she has performed at least 25
inpatient or outpatient procedures in last 24 months.
 References: Letter should come from the director of the training program or from the Chief of Dentistry
where applicant has been for past 24 months.
 Specialty Care: Dentists who have completed a residency/fellowship and/ or who have extensive ongoing
experience in that specialty area. Documentation of training and/or experience must accompany request
for specialty privileges.
 Reappointments are based on ongoing monitoring of information concerning the individual’s professional
performance, judgment, and clinical or technical skills. The applicant for reappointment must demonstrate
current competence and an adequate volume of current experience with acceptable results in the
privileges requested as a result of performance improvement activities and outcomes.
Although the following requested privileges are generally applicable across a broad range of dental / medical
conditions, they are never intended to abrogate the following principle: In every specific situation, the dentist’s
practice and exercise of clinical privileges are based upon each unique case and situation. This is the assertion by
the dentist, according to her/his best clinical judgment, and in accord with other hospital governance, that at any
particular moment, the patient’s illness and problems are within the prudent dentist’s, and the institution’s scope of
requisite skills and services. When there is a prudent cause for doubt, the dentist will consult medical references,
colleagues, specialists, or other disciplines formally and/or informally and/or request additional institutional
resources. Furthermore, whenever such means do not rectify the perceived need of additional medical expertise
the provider will assist the patient in finding an appropriate alternate provider or treatment.
Category I: Core Privileges (meets minimum thresholds above): General dental privileges are those
competencies appropriate for and expected from the graduate of an ADA accredited dental school.
Requested
Limited
(explain
limitations)
Full
Approved
Limited
(explain
limitations)
Full
Oral diagnosis, and diagnostic procedures, treatment
planning, operative dentistry, fixed and removable
prosthodontics, endodontics, periodontal treatment, occlusal
adjustment and treatment, pediatric patient treatment and
behavior management, non-surgical management of
tempromandibular disorders, anxiolysis, oral surgery to
include: extractions, soft tissue impactions, alveloplatsty,
biopsy minor tumor removal, treatment of minor dentoalveolar trauma, administration of local anesthesia.
Limitations to approved privileges:
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Category II: Advanced General Dentistry: To be eligible to apply for a special procedure listed below, the
applicant must demonstrate successful completion of an approved, recognized course when such exists, or
acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation
of competence in performing that procedure consistent with the criteria set forth in medical staff policies governing
the exercise of specific privileges. Advanced general dental privileges are those competencies appropriate for
general dentists with additional training and experience, and include the general dental core privileges and,
depending on the applicant’s training, some or all of the following:
Requested
Limited
(explain
limitations)
Approved
Full
Limited
(explain
limitations)
Full
Surgical endodontics
Extraction of complete bony impactions
Removal of hard and soft tissue lesions
Pre-prosthetic surgery
Closed reduction of jaw fracture
Limited/interceptive orthodontics
Periodontal surgery (mucogingival, grafts, etc.)
Implant placement and/or prosthetics
Qualifying Requirements: Completion of an approved 36
hour minimum CME course in implant principles, implant
placement, tissue interactions, implant prosthetic
considerations. A letter outlining the content and successful
completion of course must be submitted, or documentation
of successful completion of an approved residency in a
specialty or subspecialty which included training in implant
placement and implant prosthetics.
Oral antral fistula closure
Conscious sedation
Limitations to approved privileges:
Number in the
past two years
Requested
Limited
(explain
limitations)
Full
Approved
Limited
(explain
limitations)
Full
Nitrous oxide analgesia: Certificate of CME
documenting Certification / Recertification; or
State permit; or Letter of Reference
documenting formal training
Category III: Dental Specialty: To be eligible to apply for a special procedure listed below, the applicant must
demonstrate successful completion of an approved, recognized course when such exists, or acceptable
supervised training in residency, fellowship or other acceptable experience, and provide documentation of
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competence in performing that procedure consistent with the criteria set forth in medical staff policies governing
the exercise of specific privileges. Dental specialists privileges are those competencies appropriate for and
expected from the graduate of an ADA accredited program in their respective specialty. They include the general
core privileges, and may include supplemental privileges requested in Category II.
Requested
Limited
(explain
limitations)
Full
Approved
Limited
(explain
limitations)
Full
Periodontics: Privileges include hard and soft tissue
periodontal surgery, Complete occlusal adjustment, root
resective procedures, mucogingival surgery, Surgical
placement and management of dental implants. Qualifying
requirements: The provider must be a graduate of an ADA
accredited program in periodontics.
Oral Surgery: Privileges reflect competency in dentoalveolar surgery, hard and soft tissue oral and maxillofacial
trauma, ambulatory anesthesia, management of
odontogenic infections, orthognathic, reconstructive,
preprosthetic and TMJ surgeries, and surgical placement of
dental implants, with grafting and/or sinus lifts.. Qualifying
Requirements: The provider must be a graduate of an ADA
accredited program in oral surgery.
Pediatric Dentistry: Privileges include core privileges plus
straight wire, minor orthodontic treatment, and palatal
expansion. Qualifying Requirements: The provider must be
a graduate of an ADA accredited program in pediatric
dentistry.
Endodontics: Privileges include core privileges and
evaluate, diagnose, consult, manage, and provide therapy
and treatment for patients of all ages presenting with
conditions or disorders involving the dental pulp and
periapical tissues of the teeth. Endodontists may assess,
stabilize, and determine disposition of these patients.
Qualifying Requirements: The provider must be a graduate
of an ADA accredited program in endodontics.
Orthodontics: Privileges include core privileges and
evaluate, diagnose, consult, manage, and provide
therapy and treatment for patients of all ages presenting
with conditions or disorders involving irregularities and
malocclusion of teeth and malrelation of jaws. Orthodontists
may assess, stabilize, and determine disposition of these
patients and determine types of appliances to move and
guide teeth and jaws into proper positions and relationships.
Qualifying Requirements: The provider must be a graduate
of an ADA accredited program in orthodontics.
Limitations to approved privileges:
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DENTISTRY PRIVILEGE REQUEST FORM – Signature Page
PROVIDER NAME____________________________________
I have requested only those privileges for which by education and training, current experience and demonstrated
performance I am qualified to perform, and that I wish to exercise at
(name of
facility/service unit). It is understood I will consult with my colleagues, when appropriate, in cases of unresolved
diagnostic problems or unexpected deterioration of health status.
I understand that by requesting these privileges, I am bound by the applicable bylaws, rules and regulations, and
policies of the Dental Staff and Health Center.
____________________________________
Signature of Applicant
_____________________
Date
The Chief Dental Officer hereby recommends the clinical privileges (initial one):
________
As Noted
________
With the following exceptions, deletions, additions, or conditions:
___________________________________________________________________________________________
___________________________________________________________________________________________
_________________________________
Signature of Chief Dental Officer
_____________________
Date
As Clinical Director, I recommend that the applicant be granted clinical privileges (initial one):
_________
_________
As recommended by dental executive staff
As requested by the dental executive staff with the following exceptions,
deletions, additions, and/or conditions as noted below:
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________
Signature of Clinical Director
______________________
Date
As an agent of the Governing Board, I approve the applicant’s clinical privileges (initial one):
_________
_________
As recommended by Clinical Director
As requested by the Clinical Director with the following exceptions, deletions,
additions, and/or conditions as noted below:
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________
Governing Board Representative
Privileges granted:
From
_______________________
Date
To
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