UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

DEPARTMENT OF SURGERY

SECTION OF PLASTIC SURGERY

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/fellowship training program in Plastic Surgery. 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 plastic surgery residency/fellowship program or current competency in providing

medical/surgical management and/or treatment to patients within the scope of core privileges for Plastic Surgery.

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 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, management and treatment of all patients presenting to the plastic surgery service | | |

|Provision of consultation, including assessment, diagnosis and ordering of diagnostic studies and procedures | | |

|SPECIFIC CORE PROCEDURES: | | |

|Head and neck surgery | | |

|Hand surgery and related procedures | | |

|Breast surgery (excluding radical mastectomy) | | |

|Surgery of the integument and its defects | | |

|Regional node dissection | | |

|Abdominoplasty and associated procedures (body sculpturing) | | |

|Tissue grafts and transfers | | |

|Implantation prosthetics | | |

|Microvascular surgery | | |

|External genital surgery | | |

|Congenital anomaly reconstruction | | |

|Acquired deformity or functional deficiency reconstruction | | |

|Aesthetic (cosmetic) surgery | | |

|Maxillofacial surgery including fractures | | |

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.

SECTION OF PLASTIC SURGERY

REQUEST FOR PRIVILEGES

PAGE 2

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|Laser privileges | | |

|Moderate Sedation | | |

|The applicant is required to submit a separate letter of | | |

|request for any privilege not included on this form. | | |

________________________________________ ___________________________

Applicant’s Signature Date 7/07

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