Get University Of Utah Hospitals And Clinics Allied Health Practitioner Privilege Delineation Form. Xml

Filling out the University of Utah Hospitals and Clinics Allied Health Practitioner Privilege Delineation Form is an essential process for individuals seeking to obtain clinical privileges. This guide provides a clear and supportive approach to completing the form online, ensuring that users can navigate each section with confidence.

Follow the steps to successfully complete the privilege delineation form.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by entering your name in the designated field provided at the top of the form.
3. In the 'Date of Application' section, input the current date to indicate when you are submitting the form.
4. Select the type of patients you are providing care for by checking the appropriate box for either pediatric or adult patients.
5. In the 'General Privileges' section, review the listed capabilities. Acknowledge that you will provide high-quality palliative health care according to the standards set by relevant professional organizations.
6. Fill in the specifics regarding your role, including performing comprehensive history and physical examinations, diagnosing health problems, and ordering relevant diagnostic studies.
7. Indicate your ability to prescribe and administer medications as allowed by Utah guidelines in the section related to medication orders.
8. Complete the area that addresses emergency care procedures you are prepared to initiate in line with ACLS standards.
9. Address discharge planning activities, including referrals and communication with medical directors, if applicable.
10. Finally, ensure you have signatures from all required parties in the approval sections, which include the collaborating physician, department head, chair of the medical board, and chair of the governing body.
11. Once all sections are filled out, save your changes, and choose to download, print, or share the completed form as needed.

Complete your document online today to ensure you have the necessary privileges for your practice.