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Fairview Health Services
DENTISTRY
Delineation of Privileges
Applicant’s Name (please print):
Must be an DDS or DMD and have completed Threshold Criteria listed in the individual privilege sections. Completion of an ADA
accredited residency or college/school of dentistry program culminating in a dental degree or the international equivalent in the
specialty of Dentistry.
CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES
I Want to Work at the Following Fairview Entity
Inpatient/hospital(s)
I need to the following Fairview Entity Box on Privilege Form
Individual Fairview hospital(s)
Fairview Maple Grove Medical Center
(Ambulatory Care Center) 1, 2
Fairview Maple Grove Ambulatory Surgery Center1
University of Minnesota Medical Center, Fairview (UMMC)
Fairview Maple Grove Ambulatory Surgery Center (MGASC)
Fairview Hospital-Based Clinic
(such as UMMC Clinics, Fairview Ridges Specialty Clinic for
Children, Fairview Southdale Oncology Clinic, Fairview
Southdale Hospital Breast Center)1, 3
Individual Fairview hospital where clinic is affiliated
Fairview Free-Standing Ambulatory Clinics1
Fairview Group Practice Ambulatory Clinics (FV Clinics)
1
Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to
those practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are not
otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel.
2
Privileges granted by UMMC can also be exercised at these entities in Maple Grove in accordance with procedures available at the sites.
3
Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with
procedures available at the clinic.
COMPETENCY MEASURES DOCUMENTATION REQUIREMENTS
I am a NEW APPLICANT to Fairview or Requesting Additional Privilege(s) NOT CURRENTLY HELD at a Fairview entity - Submit
documentation listed below for requested privileges.
Core
● Out of Training Less Than 24 Months - Requirements may be met by verification of formal training program
Privileges
completion in past 24 months
● Out of Training Greater Than 24 Months - Documentation of cases required for Competency Measures may be
met by submitting the attached “Verification of Patient Management & Participation for Core Privileges
Special
Must provide one (1) of the following - training or cases must have been completed within the past 24 months:
Request
● Letter from a residency or fellowship program verifying training specific to the procedure;
Privileges
OR
● Letter or certificate from an additional training course specific to the procedure;
OR
● Documentation of specified number of cases assigned to each procedure performed (copies of operative
reports, chart notes, or a list of cases performed). Documentation must include date the procedure was performed,
type of procedure and where performed (e.g., name of hospital or other facility). Laser cases must also list the type of
laser used. Please delete all patient identifiers such as name or medical record number from documentation to protect
individual patient confidentiality.
I CURRENTLY HOLD the specific privilege(s) at a Fairview entity: Sign the attestation listed on the last page of this privilege form
attesting to the completion and satisfactory performance of the required number of cases for core and special request privileges as
noted by each privilege. NOTE: By signing the attestation, you do not need to provide additional documentation at this time;
however, Fairview will randomly audit applicants and, if selected, you will be required to provide the required documentation.
Erroneous information related to the attestation may result in immediate suspension of privileges and lead to an investigation that
may result in disciplinary action.
Q:Central-Metro-Shares\UMMC-Business\SHAREDIR\CREDENTIAILNG DEPT\Privilege Forms\Dentistry.doc
Approved: 4/30/98; Revised 10/01; 6/09 new format; 3/12;9/12
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Fairview Hospital Entity Codes
UMMC - University of Minnesota Medical Center, Fairview
FSH - Fairview Southdale Hospital
FRH - Fairview Ridges Hospital
FNH - Fairview Northland Medical Center
FLH - Fairview Lakes Medical Center
Fairview Ambulatory Entity Code
FV Clinics = Fairview Free-standing Ambulatory Clinics
MGASC= Fairview Maple Grove Ambulatory Surgery Center
Definitions/Abbreviations
Core Privileges - Privileges routinely taught in residency/fellowship programs
Special Request Privileges - Privileges not routinely taught in residency/fellowship programs; new technology or procedure; high
risk; or requires ongoing practice to maintain competency
N/A - Indicates privilege not available at the specific Fairview entity
AF - Indicates an additional form is required to request the privilege
GENERAL DENTISTRY
Threshold
Criteria
Core
Privileges
● ADA accredited residency or college/school of dentistry program culminating in a dental degree
● Board Certification does not apply to General Denistry.
Cross out privileges you do not
Check Entity(ies) Where Privileges Requested
Competency
perform
Measures/
Privileges include ability to consult,
Hospital Entities
Ambulatory
Required #
work up (including the performance of
Cases in Past
the portion of history and physical
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
examination that relates to dentistry)
and provide diagnostic, preventative,
100
and therapeutic oral health care to
(inpatient,
N/A
patients of all ages to correct or treat
ambulatory &/or
various routine conditions of the oral
consultative)
cavity. Privileges also include, but are not limited to:
● local anesthesia in the oral cavity
● Restoration of carious teeth
● Removal of teeth
● Exposing and interpreting plain and panoramic radiographs
Special Request Privileges
NOTE: You may also obtain referenced additional privilege
form (AF) at www.fairview.org/credentialing/PrivilegeForms
Competency
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
AF
AF
AF
AF
AF
AF
N/A
Check Entity(ies) Where Privileges Requested
Hospital Entities
Ambulatory
Moderate and Deep Sedation - You may also obtain
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
Laser
- By requesting laser privileges, I attest that I will only use
those lasers for which I have been trained and I will review laser
safety information at the Fairview entity prior to using a laser
5
N/A
REQUIRED DOCUMENTATION, ATTESTATION AND SIGNATURE
□ I am a NEW APPLICANT to Fairview or Requesting Additional Privilege(s) NOT CURRENTLY HELD at a Fairview
entity - Submit documentation required for Competency Measures as listed on page 1.
□ I CURRENTLY HOLD the specific privilege(s) at a Fairview entity:
By my signature below on this privilege form, I
attest to the completion in the past 24 months of at least the required number of cases listed above for each
requested privilege(s) with acceptable results based on quality improvement activities and outcomes.
NOTE: By signing the attestation below, you do not need to provide additional documentation at this time; however, Fairview will randomly
audit applicants and, if selected, you will be required to provide the required documentation. Erroneous information related to the attestation
may result in immediate suspension of privileges and lead to an investigation that may result in disciplinary action.
I understand that by making these privilege requests, I am bound by the applicable bylaws or policies of the entity at which the
privileges are requested. I also attest that my professional liability insurance covers the privileges I have requested.
_____________________________________________________
Signature
______________________
Date
VERIFICATION OF PATIENT MANAGEMENT & PARTICIPATION
FOR DENTISTRY CORE PRIVILEGES
This Section to be Completed by DENTIST Applying for Privileges
Dentist Name__________________________________ Initial Appointment___ Reappointment___
I am requesting the following core(s) privileges. I attest that I have managed and participated in or completed the
minimum number of patients/procedures listed for each of the requested core(s) within the past 24 months.
____General Dentistry - 100 patients
This Section to be Completed by CLINIC
MANAGER OR PEER* Verifying Dentist’s Patient Management &
Participation
*Must have current knowledge of Dentist’s practice
The above-referenced dentist is applying for core privileges at a Fairview hospital or clinic. Please complete the following
questions to verify the dentist has met the current clinical competency criteria for the core privileges being requested.
Thank you for your assistance.
1.
Within the past 24 months, has the above-referenced dentist managed and participated in or completed the
above-noted required number of patients/procedures in the core(s) being requested (either inpatient, ambulatory
or consultative)? Yes____ No*____ *If no, please explain below in the Additional Comments area.
2.
Do you have any concerns about this dentist performing the requested privileges?
Yes*____ No____
*If yes, please explain below in the Additional Comments area.
Additional Comments: _______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Name (please print)
Title
Phone Number
_________________________________________________________________________________________________
Signature
Date
Clinic Name and Address_____________________________________________________________________________
CLINIC MANAGER OR PEER - RETURN FORM WITHIN 1 WEEK DIRECTLY TO:
Fairview System Credentialing
Initial Appointments - Fax (612) 672-4123
Reappointments - Fax (612) 672-7733
If you have questions, please contact the Fairview System Credentialing Office at (612) 672-7700