DEPARTMENT OF SURGERY
DELINEATION OF PRIVILEGES FOR PODIATRIC SURGERY
NAME: ______________________________________________________________DATE__________________
Privileges Requested
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Amputation, Digital
Amputation, Forefoot
Amputation, Midfoot
Amputation, Transmetatarsal
Amputation, Foot
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Ankle Stabilization **
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Arthrodesis, Digital
Arthrodesis, Forefoot
Arthrodesis, Midtarsal
Arthrodesis, Rearfoot
Arthrodesis, Triple
Arthroplasty, Digital
Arthoplasty, Forefoot
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Arthoplasty, Ankle (Sub-Talar) **
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Arthoscopy, Ankle (Sub-Talar)
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Arthrotomy,Ankle (Sub-Talar) **
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A-O Fixation
Bone Graft
Bunionectomy, Capsulo-Tendon Balance
Bunionectomy with Arthrodesis
Bunionectomy with Osteotomy
Bunionectomy with Joint Resection
Bunionectomy with Prosthesis
Capsulotomy, Digital
Capsulotomy, Forefoot
Capslotomy, Midtarsal
Capslotomy, Rearfoot
Cast Application
Cavus Foot Reconstruction
Clubfoot and Vertical Talus Correction
Flatfoot Reconstruction
Fracture/Trauma, Digital (Closed or ORIF)
Fracture/Trauma, Forefoot (Closed or ORIF)
Fracture/Trauma, Tarsal (Closed or ORIF)
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Gastrocnemius Recession **
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Incision and Drainage, Superficial, Foot
Incision and Drainage, Deep, Foot
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Incision and Drainage, Superficial, Ankle
Laser Procedures, Foot **
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Metatarsal Head resection, Partial
Metatarsal Head Resection, Total
Metatarsus Adductus Correction
Neurectomy
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Exostectomy, Digital
Exostectomy, Forefoot
Exostectomy, Rearfoot
Endoscopic Plantar Fasciotomy
Excision of Neuroma, Digital
Excision of Neuroma,
Intermetatarsal
Excision of Neuroma, Foot
Excision of Accessory Bones,
Forefoot
Excision of Accessory Bones,
Rearfoot
Removal of Bone Tumor
Digital
Removal of Bone Tumor,
Metatarsal
Removal of Bone Tumor,
Midtarsal
Removal of Bone Tumor,
Rearfoot
Excision of Cutaneous Lesions
Excision of Soft Tissue Tumor
Forefoot
Excision of Soft Tissue Tumor
Rearfoot
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Neurolysis, Foot
Neurolysis, Ankle (Tarsal Tunnel)
Osteomyelitis Management, Foot
Osteotomy, Digital
Osteotomy, Lesser Metatarsal
Osteotomy, Tarsal
Osteotomy, Rearfoot, Calcaneus
Partial Metatarsectomy
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Pan Metatarsectomy
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Partial/Total Tarsectomy
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Permanent Toenail Removal
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Plantar Fasciotomy
Prosthesis, Digital
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Prosthesis, Lesser Metatarsal
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Removal of Foreign Body, Forefoot
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Removal of Foreign Body, Rearfoot
Sesamoidectomy
Sinus Tarsi Decompression
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Skin Graft
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Subtalar Arthroereisis
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Surgical Desyndactylism, Digital
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Surgical Syndactylism, Digital
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Tendo Achilles Lengthening
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Tendon Lengthening, Digital
Tendon Lengthening, Forefoot
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Tendon Lengthening, Rearfoot
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Tendon Transfer, Digital
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Tendon Transfer, Forefoot
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Tendon Transfer, Rearfoot
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Tenoplasty, Digital
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Tenoplasty, Forefoot
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Tenoplasty, Rearfoot
WOODLAND POND PRIVILEGES ONLY
_________ Wound Care
_________ Nail Care
_________ Ingrown Nail Procedures
I have requested only those privileges for which by education, training, current experience and demonstrated
performance I am qualified to perform, and that I wish to exercise at HealthAlliance facilities. I also request the
ability to do any procedure in an emergency situation.
Applicant’s Signature: ________________________________________ Date: ________________
I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and
recommend approval.
Department Chair’s Signature: ___________________________________Date: ________________
Broadway and Mary’s Avenue Campuses