Privilege request form
Coil occlusion of aneurysms
In order to be eligible to request clinical privileges for coil occlusion of aneurysms, an applicant must
meet the following minimum threshold criteria:
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Education: MD or DO
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Minimum formal training: The applicant must have completed an ACGME/AOA-accredited
residency training program in neuroradiology or endovascular surgical neuroradiology, or
must demonstrate equivalent training. Following this training, a neurointerventionalist with
experience in this procedure should proctor the applicant’s initial coil occlusion of aneurysms
procedures.
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Required previous experience: Applicants must be able to demonstrate performance of at least
20 coil occlusion of aneurysms procedures in the past 12 months.
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References: A letter of reference should come from the director of the applicant’s endovascular
surgical neuroradiology residency training program and from the proctor of the applicant’s
initial coil occlusion of aneurysms procedures. Alternatively, a letter of reference should come
from the chief of neuroradiology at the institution where the applicant has most recently
practiced.
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Reappointment: Reappointment should be based on unbiased, objective results of care
according to the organization’s existing quality assurance mechanisms.
Applicants must be able to demonstrate that they have maintained competence by showing evidence
that they have performed at least 40 coil occlusion of aneurysms procedures in the past 24 months.
In addition, continuing education related to coil occlusion of aneurysms should be required.
I understand that by making this request I am bound by the applicable bylaws or policies of the
hospital, and hereby stipulate that I meet the minimum threshold criteria for this request.
Physician’s signature: ____________________________________________________________
Typed or printed name: __________________________________________________________
Date: _________________________________________________________________________