BANNER IRONWOOD MEDICAL CENTER
Delineation of Privileges
RADIOLOGY
Physician Name: ________________________________________________________
Radiology Core Privileges
Qualifications
To be eligible to apply for core privileges in radiology, the applicant must meet the following qualifications:
Documentation of active clinical practice within the past 24 months; AND
Successful completion of an ACGME- or AOA-accredited residency in radiology or diagnostic radiology or an equivalent program;
AND
Current certification or active participation in the examination process leading to certification in radiology by the American Board of
Radiology or the American Osteopathic Board of Radiology or other board deemed to be equivalent by the Medical Executive
Committee. Board certification must be attained within 5 years of completion of training.
Please check requested privileges.
Requested Approved Not Core Privileges
Approved
Privileges included in the Radiology Core - Privileges to admit, evaluate,
diagnose, and provide treatment or consultative services for patients. Privileges
include but are not limited to: plain film interpretation, fluoroscopy, magnetic
resonance imaging with or without angiography, diagnostic venography,
arthrography, and performance of basic imaging-guided procedures with
fluoroscopy (including myelography), ultrasound, CT and MRI including biopsy,
drainage and therapeutic procedures (tube and catheter placement) and catheter
exchange over wire.
Exceptions to the Radiology Core:
Privileges included in the Teleradiology Core - Privileges to evaluate,
diagnose, and provide consultative services for patients. Privileges include but are
not limited to: plain film interpretation, magnetic resonance imaging with or
without angiography, CT imaging with or without angiography, ultrasound and
vascular ultrasound and bone density studies.
Special Procedure Privileges
To be eligible to apply for a special procedure privilege listed below, the applicant must demonstrate successful
completion of an approved and recognized course or acceptable supervised training in residency, fellowship, or other
acceptable experience; and provide documentation of competence in performing that procedure consistent with the
criteria set forth in the medical staff policies governing the exercise of specific privileges.
Requested Approved Not Procedure Criteria
Approved
Administration of IV Moderate Sedation See Moderate Sedation Criteria.
Note: A request for special procedure privileges not included on this form must be submitted to the Medical Staff Office and will be forwarded for
appropriate committee review to determine the need for development of criteria.
Radiology Privilege Criteria
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Acknowledgement of Practitioner
I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am
qualified to perform, and that I wish to exercise at Banner Ironwood Medical Center, and;
I understand that:
(a) In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable
generally and any applicable to the particular situation.
(b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such a situation my actions
are governed by the applicable section of the medical staff bylaws or related documents.
(c) If requested, I will provide documentation of my performance of cases required for procedures listed above.
(d) Privileges may only be exercised at the site(s) and/or setting(s) that have the appropriate equipment, license, beds, staff and
other support required to provide the services defined in this document.
Signed: _________________________________________________ Date: __________________________
(Practitioner)
Department Chairman Recommendations:
I have reviewed the requested clinical privileges and supportive documentation for the above named applicant and recommend action
on the privileges as noted above. _______ Approved _______Approved with Modifications _______Not Approved
Comments: ____________________________________________________________________________________
____________________________________________________________________________________
Signed: __________________________________________________ Date: ___________________________
(Department Chair)
Approved: 06/09/10
Revised: 01/31/11, 04/14/11