DEPARTMENT OF PEDIATRICS
DELINEATION OF PRIVILEGES FOR PHYSICIAN ASSISTANT & NURSE PRACTITIONER IN
NEONATOLOGY (Broadway Campus Only )
Name: ___________________________________________________Date: ______________
PLEASE NOTE: All Core Privileges, as printed below, are given to department members at the time of
appointment. SPECIAL PRIVILEGES ONLY need to be checked based on the provider’s qualifications.
Nurse Practitioners: Please attach a copy of your Collaborative Agreement to this privilege request
form.
CORE PRIVILEGES:
 Hemolytic Anemia
 Hemophilia
 Disturbances of Growth & Development
 Steroid Therapy over 1 week duration
 Nursing Privileges – Routine New born Care
 Premature Infant Care – without complications over 4 lbs.
 Premature Infant Care – without complications under 4 lbs.
 Full-term Infant Care with Complications – Non-Life Threatening – Medical
 Erythroblastosis – Mild
 Disturbances of Water & Electrolyte Balance – Mild
 Disturbances of Water & Electrolyte Balance – Severe
SPECIAL PRIVILEGES: Please check privileges requrested:









Full-term Infant Care w/Complications – Life Threatening – Medical
Full-term Infant Care w/Complications – Life Threatening – Surgical
Full-Term Infant Care w/Complications – non-Life Threatening – Surgical
Premature Infant Care w/Complications – Life Threatening – Surgical
Premature Infant Care w/ ComplicatIons – non-Life Threatening – Surgical
Premature Infant Care w/o complications-Life Threatening – Medical
Premature Infanct Care w/o Complications – non-Life Threatening – Medical
Erythroblastosis – Severe
Erythroblastosis – Requiring Exchange Transfusion
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Acknowledgment of Practitioner:
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 The Kingston Hospital.
I will perform those privileges that are outlined above and that have been agreed upon between my supervising physician
and me. (PA’s only)
Applicant’s Signature: __________________________________ Date:__________________
DEPARTMENT OF PEDIATRICS: NEONATOLOGY
PHYSICIAN ASSISTANT
AGREEMENT OF SUPERVISING PHYSICIAN FOR PA’s
In accordance with the Medical Staff Bylaws and Rules and Regulations, I agree to accept full legal and ethical
responsibility for the supervision of the above Physician Assistant’s performance of the duties and acts authorized for
him/her while under my supervision.
In addition, I agree to:
a. Be continuously available, or provide an appropriate alternate, to provide consultation when
requested and to intervene when necessary as per Medical Staff Bylaws;
b. Assume total responsibility for the care of any patient when requested by the PA or required by this
policy or in the interest of patient care;
c. Co-sign all orders entered by the PA on the medical record of all patients seen or treated by the PA.
d. Maintain privileges in all areas in which I will provide supervision to the Physician Assistant.
Signature of Supervising Physician _______________________________________Date: __________
Print Name of Supervision Physician: ____________________________________________________
I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and
recommend approval.
Department Chair’s Signature: ___________________________________Date: ________________
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