Get Clinical Privilege Form

Filling out the Clinical Privilege Form is an essential step in obtaining the necessary clinical privileges as a provider. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to successfully complete the Clinical Privilege Form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter your name in the designated 'Name of Provider' field using the format Last, First, MI.
3. Provide your rank or grade in the appropriate section.
4. Fill in the facility name where you practice.
5. In the 'Provider' section, enter the applicable provider codes in the 'Requested' column for each privilege you wish to request. Line through and initial any criteria that do not apply.
6. Sign your name at the end of Section I, confirming your requests.
7. In Section II, your supervisor will review your requests. They need to enter the approval codes in the 'Approved' column based on their review.
8. The supervisor should provide overall comments and sign their name in Section II.
9. Continue to Section III for the Credentials Committee/Function. They will evaluate your requests and provide their recommendations.
10. After all sections are filled and approved, save changes to your form. You can also download, print, or share the completed document.

Start completing your Clinical Privilege Form online today to ensure you secure the necessary privileges!