PHYSICAL MEDICINE & REHABILITATION
BASIC QUALIFICATIONS FOR INITIAL APPOINTMENT:
1.
Successful completion of an ACGME or AOA accredited residency in Physical and Rehabilitative Medicine; AND
2.
Current certification in the above noted specialty by a recognized ABMS or AOA member board or attain certification directly
following completion of training program within the time frame specified by your specialty board. AND
3.
Current competence as evidenced by active clinical practice, and performance of a cross section of the procedures or medical
management privileges being requested; AND
4.
Relevant continuing medical education.
QUALIFICATIONS FOR REAPPOINTMENT:
1.
Current competence demonstrated by an active clinical practice, and performance of a cross section of the procedures or
medical management privileges being requested; AND
2.
Acceptable outcomes in the privileges requested for the past 24 months as a result of quality assessment/performance
improvement activities; AND
3.
Maintenance of Board Certification required. Failure to obtain board certification within the required timeframe, or failure to
maintain board certification, will result in the ineligibility to apply for reappointment.
4.
Relevant continuing medical education.
ACKNOWLEDGEMENT OF PRACTITIONER:
I have requested only those specific privileges for which, by education, training, current experience and demonstrated
performance, I am qualified to perform, and which I expect to exercise at Boulder Community Hospital, and;
I attest by signature that I have met the minimum criteria for procedures/diagnoses management as stated on the
following pages within the past 24 months, and have provided documentation where specifically requested. I agree to
provide any additional documentation if requested. Documentation for minimum criteria of procedures performed
may be fulfilled from other hospital affiliations.
An emergency is defined as a condition which could result in serious or permanent harm to a patient and for
which any delay in administering treatment would add to that harm or danger. In an emergency, a physician is
permitted to exercise clinical privileges to the extent permitted by his or her license, regardless of that
individual’s department status or specific grant of clinical privileges.
I understand that:
 In exercising any privileges granted, I am constrained by all Hospital and Medical Staff policies.
 Performing procedures outside my scope of practice may result in immediate suspension and/or loss of privileges.
Applicant Signature
Date
Printed Name
TURN THIS PAGE AND REQUEST PRIVILEGES
Page 1 of 4
Boulder Community Hospital
Physical Medicine & Rehabilitation
Page 2 of 4
DO NOT WRITE IN ANY ADDITIONAL PRIVILEGES / PROCEDURES. If you wish to perform a procedure that is not
listed on this form, please contact the Medical Staff Department
ARE YOU
APPLYING
FOR THIS
PRIVILEGE
?
[ ] YES
PRIVILEGES / PROCEDURES
CRITERIA
Physical Medicine & Rehab CORE Privileges
Admission, evaluation, diagnosis and provision of non-surgical
therapeutic treatments, for patients of all ages, except as specifically
excluded from practice, with neuromuscular or musculoskeletal
disorders including the provision of consultations.
Privileges include physical examination of pain/weakness/numbness
syndromes (both neuromuscular and musculoskeletal) with a
diagnostic plan and/or prescription for treatment that may include the
use of physical agents and/or other interventions; evaluation,
prescription, and supervision of medical and comprehensive
rehabilitation goals and treatment plans. Privileges also include
palliative care. Minor peripheral nerve injections to include: carpal
tunnel, ulnar, tibial, sciatic, radial, supra scapular, etc. Privileges also
include electromyography (EMG) and nerve conduction studies, and
clinical microscopy.
[ ] YES
Physical Medicine & Rehab SPECIAL Privileges
Muscle biopsy
Initial Appointment Criteria

Must hold CORE privileges
[ ] YES
Fluoroscopy
Initial: Successful completion of
radiation safety self-study
[ ] YES
Chronic PAIN MANAGEMENT Special Privileges (Level I) 1PAIN/A
Admission, evaluation, diagnosis, consultation and provision of
treatment for patients requiring pain management. A representative list
of Level I Pain Management Privileges is stated below. It is assumed
other procedures and problems of similar complexity would be
included.
Non-Invasive Procedures (i.e. manipulation, massage, etc.)
Rehabilitation Management
Peripheral Joint Injections
Chronic Opioid Medication Management
Complex Medication Management
Trigger Point Injections
February 17, 2016
Boulder Community Hospital
Physical Medicine & Rehabilitation
Page 3 of 4
DO NOT WRITE IN ANY ADDITIONAL PRIVILEGES / PROCEDURES. If you wish to perform a procedure that is not
listed on this form, please contact the Medical Staff Department
[ ] YES
[ ] YES
[ ] YES
[ ] YES
[ ] YES
[ ] YES
Chronic INVASIVE Pain Management Privileges (Level II) 2PAIN
Admission, evaluation, diagnosis, consultation and provision of
treatment for patients requiring invasive pain management. A
representative list of Level II Pain Management Privileges follows. It is
assumed other procedures and problems of similar complexity would
be included.
Epidurals - including: Caudal, Cervical, Thoracic, and Lumbar
2PAIN/A
Peripheral Nerve Blocks - including: Ulnar, Radial, Posterior Nerve
Blocks, Tibial, and Extremities 2PAIN/B
Fluoroscopically Guided Injections (with and without contrast)
2PAIN/C
Successful completion of a Residency in:
Anesthesiology, Neurology, Radiology,
Neurosurgery, Orthopedic Surgery,
Physical Medicine & Rehabilitation, or
Pain Management.
In lieu of formal Pain Management
training within one of the Residency
program listed above, applicant’s will
need to have spent at least 25% of their
clinical practice on Chronic Pain
Management during the past 24 months
Sympathetic Plexus Blocks - including: Lumbar, Super Hypogastric,
Celiac, and Stellate Ganglion Blocks 2PAIN/D
Spine Injections - Facet Nerve Blocks, Facet Joint Injections, and
Selective Nerve Blocks (including Cervical, Lumbar and Thoracic)
2PAIN/E
[ ] YES
Chronic INVASIVE Pain Management Privileges (Level III) 3PAIN
Admission, evaluation, diagnosis, consultation and provision of
treatment for patients requiring pain management. A representative list
of Level III Pain Management Privileges follows. It is assumed other
procedures and problems of similar complexity would be included.
Initial Application Criteria
Same as for Level II, plus:
 At least one year of formal training in
an accredited Pain Management
program; OR
[ ] YES
Special Drug Delivery System: Intraspinal Drug Delivery System;
Intrathecal Catheters with Infusion Pumps; and Placement of
Subcutaneous Pump or Reservoir 3PAIN/A
 Completion of a Pain Management
Course as part of an approved
training program; OR
[ ] YES
Neurolytic Blocks (Central & peripheral) 3PAIN/B
[ ] YES
Spinal Cord Stimulator 3PAIN/C
 Completion of a specific course
covering the pain management
privileges being requested; OR
[ ] YES
Intradiscal Electrothermal Therapy (IDET) 3PAIN/D
 Comparable experience.
[ ] YES
DISC Nucleoplasty 3PAIN/F
February 17, 2016
Boulder Community Hospital
Physical Medicine & Rehabilitation
Page 4 of 4
DO NOT WRITE IN ANY ADDITIONAL PRIVILEGES / PROCEDURES. If you wish to perform a procedure that is not
listed on this form, please contact the Medical Staff Department
[ ] YES
PROCEDURAL SEDATION Privileges
Bier blocks (intravenous regional anesthesia)
[ ] YES
Brachial plexus blocks
[ ] YES
Intercostal nerve blocks
[ ] YES
Retrobulbar blocks
[ ] YES
Facial regional anesthesia
Note: Digital, Dental, Wrist and Ankle nerve blocks, along with Minimal
Sedation (anxiolysis), are included in all Core privileges and do not
need to be requested separately.
Initial Application Criteria
 Demonstration of training in
administering nerve blocks, moderate
sedation, and/or short term deep
sedation in the applicant’s residency
training program; OR
 Completion of a formal training
program in administering the level of
sedation for which privileges are
requested; AND
Performance of 2 procedures or each type
of nerve block requested during the past
24 months.
Reappointment Criteria
Performance of 1 procedure of each type
of nerve block requested during the past
24 months.
[ ] YES
Moderate Sedation
Sedation packet is located on the Scoop click on the Medical Staff
Tab
February 17, 2016
Initial and Reappointment:

Completion of the sedation self-study
packet, including post-test with a
passing score of 85%.Provide
evidence of current ACLS
certification, which included an airway
management module OR Completion
of an approved Airway Management
Skills Lab, including hands on
practice with OPAs, LMA and ET
intubation on airway simulators.

Provide evidence of current PALS
certification if practice will include
children/infants/newborns.

Sedation packet is located on the
Scoop.