DEPARTMENT OF RADIOLOGY - Hurley Medical Center



DEPARTMENT OF RADIOLOGYREQUEST FOR SPECIFIC PRIVILEGESGROUP 101.00Diagnostic Radiology1.01?Perform, Interpret, and Supervise Imaging Procedures of Plain Films1.02?Fluoroscope With or Without Contrast Agents1.03?Injection and Supervise Injection of Contrast for Contrast Studies1.04?Fluoroscopy1.05?Bronchograms1.06?Hysterosalpingograms1.07?Mammography, Breast Biopsy, and Other Related Interventions1.08?Genitourinary Imaging1.09?Computed Tomography1.10?Ultrasound1.11?Magnetic Resonance Imaging1.12?Performance and Supervision of Myelography2.00Nuclear Medicine2.01?Diagnostic Radioactive Nuclide Studies, Per License2.02?Investigate New Procedures & Radioactive Nuclides, Per License2.03?Administer/Prescribe Therapeutic Radioactive Nuclides, Per License3.00Vascular and Interventional Radiology3.01?Angiography and Venography With Transluminal Angioplasty, Stenting, and Thrombolysis3.02?Inferior Vena Cava Filter Placement3.03?Image Guided Non-Vascular Access Creation and Management3.04?Image Guided Vascular Dialysis Access Creation and Management3.05?AV Fistula3.06?Vascular Access, including Implantable Port Placement3.07?Image Guided Gastrostomy, Jejunostomy, and Related Interventions like Biopsy, Dilatation, and Stenting of the GI Tract3.08?Percutaneous Nephrostomy, Cystostomy, and Related Interventions like Dilatation, Biopsy, Stenting, and Stone Management3.09?Image Guided Biliary Drainage, Dilatation, Biopsy, Stenting, and Stone Management3.10?Image Guided Percutaneous Biopsy3.11?Image Guided Drainage of Fluid Collection3.12?Lymphangiography and Related Interventions3.13?Embolization of Arteries and Veins, including Chemo Embolization, and Embolization with Radioactive Particles3.14?Intravascular Brachytherapy3.15?Image Guided Pain Management, including Vertebroplasty and Percutaneous Disc Disease Management3.16?Neuroangiography and Related Interventions________________________________________________________________________ SignatureDate************************************************************************Department:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed, but not recommended:_____________________________________________________________________________ChairpersonDateMedical Staff Executive Committee:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed, but not recommended:_____Date______________Board of Hospital Managers:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed, but not recommended:_____Date______________Note:If privileges are denied, limited, or granted other than requested, documentationmust be provided. ................
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