CLINICA ADELANTE, INC.
PHYSICIAN PRIVILEGING CHECK LIST
Practitioner Name:
Specialty:
Signature:
Application Date:
To be completed by Medical Staff Services Department
Credentials have been verified and meet requirements.
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Health status has been evaluated and meets requirements.
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Continuing medical education has been verified and meets requirements.
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Performance evaluations have been completed and meet requirements.
Please check the boxes next to the appropriate areas of clinical privileges you are requesting.
PRENATAL CARE
Request
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SURGICAL PROCEDURES (continued)
Approved
Routine, Prenatal Care
Ultrasound, First trimester
Ultrasound, Second trimester
Ultrasound, Third Trimester
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GENERAL ADULT CARE
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General care, simple, routine
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GENERAL OB/GYN CARE
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Bartholin abscess w/ward catheter
placement
Bartholin abscess marsupialization
Cervical biopsy
Cervical LEEP
Cervical polypectomy
Colposcopy with/without biopsy
Endo-cervical curettage
Endometrial biopsy
IUD, insertion
IUD, removal
Norplant, insertion
Norplant, removal
NST Interpretation
Vulvular biopsy
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SURGICAL PROCEDURES
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Anoscopy
Aspiration of breast cyst
Digital Block anesthesia
Excision of superficial benign tumors
Excision of sebaceous cyst
Fingernail/toenail care, nail removal
Flexible sigmoidscopy
Flexible sigmoidscopy w/biopsy
Hemorrhoids, thrombosed
Clinica Adelante, Inc.
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Request
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Approved
Hemorrhoids, internal bleeding
Incision and drainage of abscess
Newborn Care, circumcision
Skin Biopsy:
Excisional biopsy, extremities
Excisional biopsy, face
Vasectomy
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LACERATION REPAIRS
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Simple
Complex, layered
Facial
ORTHOPEDICS
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Splint, simple fractures or sprains
Casting non-displaced fractures
Short Arm
Long Arm
Short Leg
Short Leg, walking
Manipulation of dislocations:
Nursemaids elbow
Finger joints
Shoulder
Hip
Joint aspiration/injections
Shoulder
Elbow
Hip
Knee
Ankle
Wrists
Digits
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Revision Date: May, 2003
Practitioner Name:
Specialty:
Signature:
Application Date:
PEDIATRIC CARE
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General care, simple, routine
OTHER REQUESTED PROCEDURES
Request
Approved
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I have reviewed the above list and have checked the procedures to which I am limiting my practice. I have been
trained accordingly and request permission to do these procedures. I understand that I may be required to prove
training and competence in specific procedures checked. I agree that to add additional procedures, I must
demonstrate adequate training and competency before performing them on Clinica Adelante, Inc. patients.
Provider Signature
Date
The above named provider has been granted privileges for the procedures checked for the patients of Clinica
Adelante, Inc.
Matthew M. King, MD
Medical Director
Privileges will be:
 Supervised
Privileges Effective:
Date
 Unsupervised
through
The above named provider has been granted OB/GYN privileges for the procedures checked for the patients of
Clinica Adelante, Inc.
Rafael Mendoza, MD
OB/GYN Director
Privileges will be:
Privileges Effective:
Clinica Adelante, Inc.
 Supervised
Date
 Unsupervised
through
Origination Date: May, 2002