DEPARTMENT OF PSYCHIATRY
DELINEATION OF PRIVILEGES
(Physicians and Nurse Practitioners)
NAME: _______________________________________________
Date: __________________
BLS (required) – Please attached current certificate
Qualifications: All applicants shall be Board Certified or Board eligible having successfully completed a residency
training program (and fellowship if applicable) which is accredited by the Accreditation Council for Graduate Medical
Education of the American Medical Association or by the American Osteopathic Association or by another graduate
medical education accrediting body which the Executive committee determines has equivalent equipment for
accreditation.
Yes
___
No
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
General Clinical Privileges
Diagnosis and treatment of mental disorders – inpatients, outpatients and EPCC
Disorders in adolescence and childhood
Mental disorders due to other medical conditions
Psychoactive substance related disorders
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Factitious disorders
Dissociative disorders
Sexual and gender identity disorders
Eating disorders
Sleep disorders
Impulse-control disorders
Adjustment disorders
Personality Disorders
___
___
___
___
___
___
___
___
Subspecialty Privileges
Geriatric Psychiatry
Adolescent Psychiatry
Child Psychiatry
Forensic Psychiatry
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Substance Abuse
Differential Diagnosis
Substance Dependence and Abuse Treatment
Uncomplicated Alcohol Detoxification
Uncomplicated Sedative/Hypnotic Detoxification
Uncomplicated Opiate Withdrawal
Uncomplicated Cocaine Withdrawal
Uncomplicated Mixed Substance Withdrawal
Core Medical Privileges (require approval of the Chair of Internal Medicine)
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
__
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Minor Muscle, tendon, fascia, bursa, or nerve trauma requiring topical wound care/observation
only
Minor nasal hemorrhage
Fluorescein test for foreign bodies or corneal abrasions
Mild Cirrhosis
Mild Hepatitis
Stable Peptic Ulcer
Stable Pneumonia, uncomplicated
Emphysema, uncomplicated
Stable Asthma, controlled with inhalers
Management of stable congestive heart failure with consultation
Management of stable coronary heart disease responsive to routine treatment,
with consult
Stable Angina, responsive to routine treatment
Hypertension, essential stable
Diabetes Mellitus, stable, on treatment
Thyroid conditions, stable, on treatment
Gout
Anemia: differential diagnosis
Treatment of iron deficiency anemia
Treatment of B12 or folate deficiency
Migraine or vascular headache, management after diagnostic assessment by Neurologist
Convulsive states, stable, on treatment
Dementia, differential diagnosis
Infectious Diseases, mild, not requiring isolation or intravenous therapy
Radial Arterial Puncture
Spinal Tap
I have requested only those privileges for which by education, training, current experience and demonstrated
performance I am qualified to perform, and that I wish to exercise at HealthAlliance facilities. I also request the
ability to do any procedure in an emergency situation.
Signature of Applicant__________________________________________Date____________________
Signature of
Department Chair for Psychiatry _______________________________________Date ____________________
Broadway and Mary’s Avenue Campuses
If Core Medical Privileges are requested:
Signature of
Department Chair for Internal Medicine___________________________________Date __________________
Broadway and Mary’s Avenue Campus