Privilege request form
Hematology
In order to be eligible to request clinical privileges in hematology, an applicant must meet the following
minimum threshold criteria:

Basic education: MD or DO

Minimum formal training: The applicant must demonstrate successful completion of an
ACGME-/AOA-accredited residency program in internal medicine followed by completion of a
two-year formal residency training program in hematology.

Required previous experience: The successful applicant must be able to demonstrate that he or
she has managed hematologic conditions for least 50 patients in the past 12 months.

References: A letter of reference should come from the director of the applicant’s hematology
residency program. Alternately, a letter of reference should come from the head of hematology
at the institution where the applicant most recently practiced.

Core privileges: Core privileges in hematology include being able to admit, evaluate, diagnose,
treat, and provide consultation to patients (including critically ill patients in the intensive care
unit) of all ages, except as specifically excluded from practice, with diseases and disorders of
the blood, spleen, lymph glands, and immunologic system, such as anemia, clotting disorders,
sickle cell disease, hemophilia, leukemia, and lymphoma. Core privileges also include the
ability to assess, stabilize, and determine the disposition of patients with emergent conditions
consistent with medical staff policy regarding emergency and consultative call services.
Privileges include, but are not limited to, the following:
 Administration of chemotherapeutic agents and biological response modifiers through
all therapeutic routes
 Bone marrow aspiration and biopsy, and interpretation
 Diagnostic lumbar puncture
 Management and care of indwelling venous access catheters
 Performance of history and physical exam
 Therapeutic phlebotomy
 Therapeutic thoracentesis and paracentesis

Reappointment: Reappointment should be based on unbiased, objective results of care
according to the organization’s quality assurance mechanisms.
Applicants must be able to demonstrate that they have maintained competence by documenting that
they have successfully managed hematologic conditions in at least 50 patients annually over the
reappointment cycle.
In addition, continuing education related to hematology 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: ______________________________________________