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NAME____________________________________________________________DATE __________________
HealthAlliance
DELINEATION OF PRIVILEGES FOR DEPARTMENT OF SURGERY / ENT
Please indicate to which HealthAlliance healthcare facility(s) you are interest in applying:
 The Kingston Hospital (TKH)
 Benedictine Hospital (BH)
 Margaretville Hospital (MH)
 Woodland Pond (WP)
Not.
Req.
Privilege
Req.
EAR SURGERY
External Ear
Excision of lesions
Repair
Skin graft
Internal Ear
Tympanoplasty (graft)
THROAT SURGERY
Biopsy of Tonsils
Tonsillectomy
Anenoidectomy
Laryngoscopy
Excision of tumors of vocal cords
Repair vocal cords
Excision of Uvula
Mastoidectomy
NOSE SURGERY
Removal nasal polyps
Repair deviated septum
Repair fracture
SINUS SURGERY
Frontal
Maxillary
CONSCIOUS SEDATION (ACLS required)
Comments
NAME____________________________________________________________DATE __________________
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 Campus