This privilege is available in the following specialty delineation’s: anesthesiology, radiology, neurosurgery, neurology, physical medicine & rehabilitation, or pain management.
Qualifications
To be eligible to apply for privileges in pain management the applicant must present documentation to support:
 Evidence of training of PM during residency;
or
 a formalized fellowship in PM which included work-up, diagnosis and treatment of pain problems; and
 Evidence of successful performance of at least 10 invasive pain management procedures during past 24 months
(e.g. nerve blocks, implantation of electrical stimulators, catheters and pumps). and
 Current ACLS certification (or must obtain certification within 6 months).
Reappointment
 Applicants must be able to demonstrate that they have maintained competence by showing evidence that they have provided inpatient and/or consultative pain services for at least 50 patients over the reappointment cycle.
 Acceptable results in the privileges requested for the past 24 months as a result of quality assessment/ performance improvement activities and outcomes.
 Current ACLS.
Grandfather clause.
No portion of these delineated privileges shall be construed to permit, solely on the basis of provisions contained therein, reduction of operative privileges held by any current staff member at the time this form becomes effective.
Check here to request core privileges. Cross out any core privilege that you do not perform in your practice.
Work-up, admission, evaluation, diagnosis, or treatment of acute and chronic pain. Minor procedures to include trigger point injections, subcutaneous infiltration, intra-muscular injections, management of PCA pumps, management of continuous epidural infusions, spinal anesthesia.
List any additional pain management procedures not included above that you would like privileges to perform at LUH.
If you are requesting additional privileges (e.g. neurolytic techniques, implantable technology, etc) that were a part of your residency or fellowship training, please circle R (residency) F (fellowship) in appropriate box*. All other procedures must be accompanied by documentation of training and/or experience**.
R F
R F
R F
R F
R F
R F
R F
R F
R F
R F
* Special procedures requested will be sent to the appropriate residency/fellowship program for verification.
** Any new technology/procedure requests must be approved prior to requesting privilege. Contact Medical Staff
Services for a copy of the New Technology/Procedure Briefing Form.
Acknowledgement of Practitioner: I attest that I am competent to perform the procedures as requested and have attached supporting documentation where needed and agree to provide additional documentation if requested. I understand that in making this request I am bound by the applicable bylaws and/or policies of the hospital and medical staff.
Applicant Signature: _____________________________
H:\Credentialing - Privileges\Core\Core Privileges\Pain Management Core.doc
Date:____________________