Utah Navajo Health System, Inc.
DELINIATION OF PRIVILEGES:
PODIATRY
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Applicant Name
Care limited to the foot and ankle.
***All care and procedures are limited to that which can be supported and performed in an outpatient setting.***
In the case of an emergency, any member of the Medical Staff, to the degree permitted by his/her license and
regardless of Medical Staff status, service or clinical privileges, shall be permitted to do everything possible to save
the life of a patient or to save a patient from serious harm.
REQUESTED PROCEDURES:
General foot care
Orthothic casting and dispensing
Diabetic foot
Screening
Ulcer care
Ingrown toenail
Chemical ablation
Sharp ablation
Excision neuroma
Excision exostosis
Excision ganglion cysts
Excision cysts
Fracture care, initial and follow up
Foot
Ankle
Injection therapy
Warts on the foot
Hammer toe correction
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Other procedures not listed
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Applicant attests that they possess adequate clinical training and experience for requested privileges.
Applicant understands that the completion of this form does not preclude applicant from requesting additional
privileges at a later date.
Applicant understands that clinical privileges expire and must be renewed after two years.
Signatures of applicant and Chief Medical Officer affirm the ability of applicant to perform the mental and physical
tasks necessary for the scope of practice requested.
I authorize and release from liability, any hospital, licensing board, certification board, individual
or institution that in good faith and without malice, provides necessary information for the
verification of my professional credentials for membership to the Medical Staff Utah Navajo
Health System, Inc.
Applicant Signature
Date
Medical Director approval of requested privileges
Date
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