DEPARTMENT OF RADIOLOGY
REQUEST FOR SPECIFIC PRIVILEGES
GROUP 10
1.00 Diagnostic Radiology
1.01 ☐ Perform, Interpret, and Supervise Imaging Procedures of Plain Films
1.02 ☐ Fluoroscope With or Without Contrast Agents
1.03 ☐ Injection and Supervise Injection of Contrast for Contrast Studies
1.04 ☐ Fluoroscopy
1.05 ☐ Bronchograms
1.06 ☐ Hysterosalpingograms
1.07 ☐ Mammography, Breast Biopsy, and Other Related Interventions
1.08 ☐ Genitourinary Imaging
1.09 ☐ Computed Tomography
1.10 ☐ Ultrasound
1.11 ☐ Magnetic Resonance Imaging
1.12 ☐ Performance and Supervision of Myelography
2.00 Nuclear Medicine
2.01 ☐ Diagnostic Radioactive Nuclide Studies, Per License
2.02 ☐ Investigate New Procedures & Radioactive Nuclides, Per License
2.03 ☐ Administer/Prescribe Therapeutic Radioactive Nuclides, Per License
3.00 Vascular and Interventional Radiology
3.01 ☐ Angiography and Venography With Transluminal Angioplasty, Stenting, and Thrombolysis
3.02 ☐ Inferior Vena Cava Filter Placement
3.03 ☐ Image Guided Non-Vascular Access Creation and Management
3.04 ☐ Image Guided Vascular Dialysis Access Creation and Management
3.05 ☐ AV Fistula
3.06 ☐ Vascular Access, including Implantable Port Placement
3.07 ☐ Image Guided Gastrostomy, Jejunostomy, and Related Interventions like
Biopsy, Dilatation, and Stenting of the GI Tract
3.08 ☐ Percutaneous Nephrostomy, Cystostomy, and Related Interventions like
Dilatation, Biopsy, Stenting, and Stone Management
3.09 ☐ Image Guided Biliary Drainage, Dilatation, Biopsy, Stenting, and Stone
Management
3.10 ☐ Image Guided Percutaneous Biopsy
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3.11 ☐ Image Guided Drainage of Fluid Collection
3.12 ☐ Lymphangiography and Related Interventions
3.13 ☐ Embolization of Arteries and Veins, including Chemo Embolization, and
Embolization with Radioactive Particles
3.14 ☐ Intravascular Brachytherapy
3.15 ☐ Image Guided Pain Management, including Vertebroplasty and
Percutaneous Disc Disease Management
3.16 ☐ Neuroangiography and Related Interventions
________________________________________________________________________
Signature Date
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Department:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed, but not recommended:_____
________________________________________________________________________
Chairperson Date
Medical Staff Executive Committee:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed, but not recommended:_____
Board of Hospital Managers:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed, but not recommended:_____
Date______________
Date______________
Note: If privileges are denied, limited, or granted other than requested, documentation must be provided.
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