________ Tribal Health Clinic
Dentistry Clinical Privileges
Name: ______________________________________
To be eligible to apply for core privileges in dentistry, the applicant must meet the following
qualifications:
Mark “x” all that apply
DDS or DMD: Successful completion of an ADA accredited school of dentistry
AND/OR
Certificate Advanced General Practice Residency AGPR
(Date) __________
Certificate one year General Practice Residency
(Date)___________
Specialty Residency in Dentistry
(type) ___________
Board Certified (Date) __________
Board eligible or qualified
• Current certification or active participation in the examination process leading to certification by
the relevant American Dental Board.
• New applicants may be requested to provide documentation of the number and types of cases
during the past 24 months. Applicants have the burden of producing information deemed
adequate by the hospital for a proper evaluation of current competence and other qualifications.
AHA PALS certified (Date) __________
AHA ACLS certified (Date) __________
AHA CPR certified (Date) __________
Other clinical certification (State certification and date) ______________________
Category of _________ Medical Staff Membership:
Regular (Full time ______employee licensed dental provider)
Associate (Non-_____ employee licensed dental provider, e.g. contractor)
INTRODUCTION: This Privileges Request Form must be accompanied or preceded by a completed
_________Medical Staff Application, including the necessary supporting documents.
In filling out and signing this privilege request form, the applicant understands and will comply
with the following concept that when embarking upon the medical care of a patient at _______:
Although the following requested privileges are generally applicable across a broad range of dental /
medical conditions, they are never intended to abrogate the following principle: In every specific
situation, the dentist’s practice and exercise of clinical privileges are based upon each unique case and
situation. This is the assertion by the dentist, according to her/his best clinical judgment, and in accord
with other hospital governance, that at any particular moment, the patient’s illness and problems are
within the prudent dentist’s, and the institution’s scope of requisite skills and services. When there is a
prudent cause for doubt, the dentist will consult medical references, colleagues, specialists, or other
disciplines formally and/or informally and/or request additional institutional resources. Furthermore,
whenever such means do not rectify the perceived need of additional medical expertise the provider will
assist the patient in finding an appropriate alternate provider or treatment.
Dentistry core privileges
Requested Category one: General Dentistry core privileges
General dental privileges are those competencies appropriate for and expected from the
graduate of an ADA accredited dental school. Such as: oral diagnosis, and diagnostic
procedures, treatment planning, operative dentistry, fixed and removable prosthodontics,
endodontics, periodontal treatment, occlusal adjustment and treatment, pediatric patient
treatment and behavior management, non-surgical management of tempromandibular
disorders, anxiolysis, oral surgery to include: extractions, soft tissue impactions,
alveloplatsty, biopsy minor tumor removal, and treatment of minor dento-alveolar trauma.
Co-admission is to be done in conjunction with a staff Oral and Maxillofacial Surgeon or
staff physician of an appropriate specialty.
Special procedures/techniques (see Qualifications and/or specific criteria*)
To be eligible to apply for a special procedure listed below, the applicant must
demonstrate successful completion of an approved, recognized course when such exists, or
acceptable supervised training in residency, fellowship or other acceptable experience, and
provide documentation of competence in performing that procedure consistent with the
criteria set forth in medical staff policies governing the exercise of specific privileges.
Category two: Advanced General Dentistry
Advanced general dental privileges are those competencies appropriate for general dentists with
additional training and experience, and include the general dental core privileges and, depending on
the applicant’s training, some or all of the following:
Procedure Requested:
Surgical endodontics
Complete bony impactions
Removal of hard and soft tissue lesions
Treatment in OR
Pre-prosthetic surgery
Partial bony impactions
Closed reduction of jaw fracture
Minor orthodontic treatment
Periodontal surgery
Mucogingival surgery
Requested Administration of moderate sedation
See Credentialing Policy for Sedation and Analgesia by Non-Anesthesiologists. This policy
requires proficiency in airway management in patients over 12 years of age: by either completion
of ACLS provider course and successful completion of a written exam on Moderate
Sedation/Analgesia; OR demonstrated airway management competency as evaluated by
Anesthesiology in the Operating Room and successful completion of a written exam on Moderate
Sedation/Analgesia. For patients over 6 months and under 12 years of age: by either completion
of PALS provider course and successful completion of a written exam on Moderate
Sedation/Analgesia; OR demonstrated airway management competency as evaluated by
Anesthesiology in the Operating Room and successful completion of a written exam on Moderate
Sedation/Analgesia. Maintenance of Privilege: Practice meets acceptable standards of care as
documented by provider profile of outcomes of sedation for the previous two years and assessed
by the individuals Department Chief.
Category three Dental Specialties
Dental specialists privileges are those competencies appropriate for and expected from the graduate
of an ADA accredited program in their respective specialty. They include the general core privileges,
and may include supplemental privileges requested in category two.
Requested: Periodontics
Privileges include hard and soft tissue periodontal surgery, Complete occlusal adjustment, root
resective procedures, mucogingival surgery, Surgical placement and management of dental
implants. Qualifying requirements The provider must be a graduate of an ADA accredited
program in periodontics.
Requested: Oral Surgery
Privileges reflect competency in dento-alveolar surgery, hard and soft tissue oral and
maxillofacial trauma, ambulatory anesthesia, management of odontogenic infections,
orthognathic, reconstructive, preprosthetic and TMJ surgeries, surgical placement of dental
implants, with grafting and/or sinus lifts, and hospital tertiary care. Qualifying Requirements
The provider must be a graduate of an ADA accredited program in oral surgery.
Requested: Pediatric Dentistry
Privileges include core privileges plus straight wire, minor orthodontic treatment, palatal
expansion, treatment of patients in the O.R. Qualifying Requirements: The provider must be a
graduate of an ADA accredited program in pediatric dentistry.
Dental implant surgery
Requested Completion of an approved 36 hour minimum CME course in implant principles, implant
placement, tissue interactions, implant prosthetic considerations. A letter outlining the content and
successful completion of course must be submitted, or documentation of successful completion of an
approved residency in a specialty or subspecialty which included training in implant placement and
implant prosthetics.
______________ Health Clinic Clinical Privileges Approval Sheet
Name: _______________________________________
1. Acknowledgement of practitioner
I have requested only those privileges for which by education, training, current experience and
demonstrated performance I am qualified to perform and for which I wish to exercise at the ________
Tribal Health Clinic, and I understand that
(a) In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation
(b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in
such situation the applicable section of the medical staff bylaws or related documents governs my
actions.
Signed: ______________________________________Date: ________________________
2. Department chair’s recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and make the following recommendation(s):
Privilege
Condition/Modification/Explanation
1.
2.
3.
4.
Notes:
Department Chair Signature: _____________________________Date: __________________________
3. Credentials Committee recommends that the applicant be granted clinical privileges:
s recommended by the supervisor with the following exceptions/conditions/modifications:
Comments: _______________________________________________________
_________________________________________________________________
Signature _______________________________
Chairman, Credentials Committee
Date ___________________
4. Governing Body: Clinical Privileges are granted as recommended by the Executive Committee.
recommended by the Credentials Committee
s as recommended by the Credentials Committee with the following
exceptions/conditions/modifications:
Comments: ____________________________________________________________________
Signature _______________________________
For the Governing Body
Date ___________________