Balboa Surgery Center
1101 Bayside Drive, Suite 100
Newport Beach, CA 92625
(949)718-6900/Fax (949)718-9367
CLINICAL PRIVILEGE DELINEATION
Printed Name : ___________________________________________
Instructions: Please indicate those privileges you are seeking by placing a check under “Request”. Privileges highlighted
with an asterisk (*) requires documentation of training/experience.
Request
Privilege
I
Approved
IA
Deferred
Denied
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Admit, diagnose and treat
History & Physical Specific to Podiatry
Assist at Surgery
Excision of cutaneous lesions, nail matrix and foreign
body of digit
Class II ForeFoot Surgery
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Arthroplasty of lesser toes
Removal of Foreign Body
Excision of Intermetatarsal Neuroma
Syndactylism of toes
Bunionectomy without Osteotomy
Bunionectomy with Osteotomy
Osteotomy of Metatarsal
Osteotomy of Phalanges
Plantar Condylectomy
Tendon Repair in Metatarsal
Taylor Bunionectomy
Open Repair of Fracture
Sesamoidectomy of MP Joints
Fusion of Metatarsal and Phalanges
Silastic Implant of MP Joint
Class III Rearfoot Surgery Includes- surgery upon
osseous, articular, and soft tissue structures
proximal to Lisfarc’s joint including, but not limited
to the following:
Complicated Incision and Drainage of Infections
Tarsal Ostectomies
Complicated Excision of Soft Tissue Masses such
as ganglions, granulomas, inclusion cysts and
Plantar Fibromatoses(Plantar Fasciotomy)
Complicated Extirpation of Foreign Body
Plantar Fasciotomy and/or Excision of Inferior
Calcaneal Spur
Nerve Decompressions
Class IV Reconstructive Surgery of the Rear
Foot/Ankle - Documentation of Training Required
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Fusions
Tarsal Osteotomies
Resection of Tarsal Coalitions or Bars
Complicated Tumors
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Tendon Recessions and Transfers
Open Surgical Management of Trauma
Open Surgical Management of Infections with
Reconstruction
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Complicated Soft Tissue Reconstruction
Non-diagnostic Arthroscopy
Special Procedures- Documentation of training
Required
Laser – CO2
Medical Acupuncture
Anesthetic
Administration of Local Anesthetic
Administration of topical Anesthetic
Other (Please itemize):
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I hereby request permission to perform the above procedures for which I have documented qualifications. I have not
requested privileges for any procedure for which I am not qualified. I am familiar with the laws of this state governing
the practice of medicine and pledge to abide by these laws.
Signature ________________________________________
Date_____________________________
For Department Use Only
□ Approved Class IA
□ Approved Class I
□ Approved Class IA as Modified
□ Approved Class I as Modified
□ Deny
□ Deny
Comments: __________________________________
Comments: ____________________________
Signature: ___________________________________
Medical Director
Signature: _____________________________
Governing Board
Date:_______________________________________
Date:__________________________________
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