CLINICAL PRIVILEGES NEUROLOGIST

AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 an 110!.

"RI#CI"A$ "UR"OS%: To e&ne the scope an li'its o( practice (or ini)i*al pro)iers. "ri)ile+es are ,ase on e)al*ation o( the ini)i*al-s
creentials an per(or'ance.
ROUTI#% US%: In(or'ation on this (or' 'a. ,e release to +o)ern'ent ,oars or a+encies, or to pro(essional societies or or+ani/ations, i(
neee to license or 'onitor
pro(essional stanars o( health care pro)iers. It 'a. also ,e release to ci)ilian 'eical instit*tions or or+ani/ations 0here the pro)ier is
appl.in+ (or sta1 pri)ile+es
INSTRUCTIONS
APPLICANT: In Part I, enter Code 1, 2, or 4 in each REQUESTED block for every rivile!e li"ted# Thi" i" to reflect c$rrent caability and "ho$ld not con"ider
any kno%n facility li&itation"# Si!n and date the for&# 'or%ard the for& to yo$r Clinical S$ervi"or# (Make all entries in ink.)
CLINICAL SUPERVISOR: In Part I, $"in! the facility &a"ter rivile!e" li"t, enter Code 1, 2, (, or 4 in each )ERI'IED block in an"%er to each re*$e"ted rivile!e#
In Part II, check aroriate block either to reco&&end aroval, to reco&&end aroval %ith &odification, or to reco&&end di"aroval# Si!n and date the for&#
'or%ard the for& to the Credential" '$nction# (Make all entries in ink.)
CODES: 1. Fully competent !t"!n #e$!ne# %cope o$ p&'ct!ce. (Clinical oversight of some allied health providers is required as defined in AFI 44-119.)
(. Supe&)!%!on &e*u!&e#. (nlicensed!uncertified or lac"s current relevant clinical e#perience.)
+. Not 'pp&o)e# #ue to l'c, o$ $'c!l!ty %uppo&t. ($eference facilit% master privileges list.)
-. Not &e*ue%te#.not 'pp&o)e# #ue to l'c, o$ e/pe&t!%e o& p&o$!c!ency0 o& #ue to p"y%!c'l #!%'1!l!ty o& l!m!t't!on.
C2ANGES: +ny chan!e to a verified,aroved rivile!e" li"t &$"t be &ade in accordance %ith +'I 44-11.#
NA3E OF APPLICANT (&ast' First' (iddle Initial)

NA3E OF 3EDICAL FACILIT4

I. LIST OF CLINICAL PRIVILEGES NEUROLOGIST
Re*$e"ted )erified Re*$e"ted )erified
A. Elect&oencep"'lo5&'m I. Pe&!p"e&'l ne&)e 1loc,%
6. E)o,e# potent!'l% 7. C'&ot!# #uple/ ult&'%ono5&'p"y
C. Elect&omyo5&'p"y 8. T&'n%c&'n!'l #opple&
D. Ne&)e con#uct!on )eloc!t!e% L. C"emo#ene&)'t!on
E. Lum1'& punctu&e 3. Ot"e& ()pecif%)
F. Lum1'& punctu&e !t" $luo&o%copy 1.
G. 3u%cle 1!op%y (.
2. Ne&)e 1!op%y +.
SIGNATURE OF APPLICANT
DATE

II. CLINICAL SUPERVISOR9S RECO33ENDATION
RECO33END APPROVAL RECO33END APPROVAL :IT2 3ODIFICATION RECO33END DISAPPROVAL
(Specify below) (Specify below)












SIGNATURE OF CLINICAL SUPERVISOR ;Inclu#e type#0 p&!nte#0 o& %t'mpe# %!5n'tu&e 1loc,<


DATE

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