Maxim Physician Resources
Dermatology
Skills Checklist
Enter the appropriate provider code in the blank next to the procedure. Failure to fill this
out correctly can delay the screening process.
Provider Codes
1 Fully competent to perform
2 Competent with supervision
3 Not requested due to lack of expertise
Please check all that apply to your scope of practice.
General Procedures
___ Inpatient General Clinical Privileges Customary to the Practice of Dermatology
___ Outpatient General Clinical Privileges Customary to the Practice of Dermatology
Specific Procedures
1. Dermatologic Surgery
___ Mohs Micrographic Surgery
___ Tumescent Liposuction
___ Skin Biopsy
___ Cryosurgery
___ Electrodesiccation & curettage
___ Electrodesiccation (telangiectasia, skin tags, warts, SK's, etc.)
___ Excision of skin lesions
___ Dermabrasion
___ Nail Surgery
___ Skin Flaps and Grafts
___ Pinch Grafts
2. Laser Surgery
___ CO2 Pulsed Laser
___ Pulsed Dye Laser
___ Q-Switched ND-Yag
___ Krypton Laser
3. Pathology
___ Dermatopathology
___ Dermatoimmunopathology
4. Injections
___ Vein Sclerosis
___ Tissue Augmentation (Collagen)
___ Injection of Cutaneous Lesions w/ Chemotherapy
___ Botox
5. Patch Testing
___ Patch Testing
6. Phototherapy
___ Ultraviolet Light
___ Non-Augmented UVB
___ PUVA
___ Photopheresis and plasmapheresis
___ Concious Sedation
Printed Name: ________________________________________________________________
Signature: _________________________________________________ Date: ____________