UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

DEPARTMENT OF MEDICINE

SECTION OF HEMATOLOGY/ONCOLOGY

REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: MD or DO

TRAINING:

Successful completion of an approved residency training program in Internal Medicine and completion of

an approved fellowship program in Hematology/Oncology. Applicant must meet the requirements for

board certification outlined in the Medical Staff Bylaws.

EXPERIENCE:

The initial applicant must be able to demonstrate training and/or experience on a level commensurate with

specialty training from an accredited Internal Medical residency program and fellowship program in

Hematology/Oncology or current competency in providing medical management and/or treatment to patients

within the scope of core privileges for Hematology/Oncology. Adequate documentation of this performance

requires submission of a case list and a reference letter. All initial applicants at completion of residency and/or

fellowship must provide an official case list and letter of recommendation assessing performance from the

Residency and/or Fellowship Program Director. All initial applicants beyond 12 months of residency/fellowship

completion must provide a case list from the hospital where the applicant has been actively practicing for the last

year and a letter of recommendation assessing performance from the hospital’s Chief of Staff or Department Chair.

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.

according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result

of care according to the hospital’s existing quality mechanisms.

CORE PRIVILEGES:

(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing list

but rather reflective of the categories/types of privileges included in the core.)

REQUESTED GRANTED

|Admission of patients | | |

|Evaluation, diagnosis, and provision of non-surgical treatment including consultation for patients admitted or | | |

|in need of care to treat general medical problems | | |

|Evaluation, diagnosis, treatment and consultation for the care and management of patients | | |

|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 | | |

|Bone marrow aspiration and biopsy | | |

|Lumbar punctures | | |

|Management and care of indwelling venous access catheters | | |

|Therapeutic phlebotomy | | |

|Thoracentesis | | |

|Paracentesis | | |

|Ordering and/or administration of chemotherapeutic agents and biological response | | |

|modifiers through therapeutic routes | | |

Applicants requesting any other special privileges listed below must present documentation of training in

each privilege requested with a letter from the training director attesting to the applicant’s competence

and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff

and the Governing Board of University Hospital.

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|The applicant is required to submit a separate letter of request for any privilege not included on this form. | | |

________________________________________ ___________________________

Applicant’s Signature Date 8/07

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