Clinical Privileges in Endocrinology

Name of the doctor………………………………………………………………………………

Initial Appointment

Reappointment

Qualifications: Successful completion of a DM in Endocrinology or equivalent degree from a University recognized

by the Medical Council of India. Any exceptions shall be described by the Coordinator of the Service for review
and approval by the Credentialing and Privileging Committee.

For exclusive Diabetologist Privileges the candidate should have a MD (Medicine) from a MCI recognized University
and have a fellowship in Diabetes/Post graduate degree in Diabetes or has 3 years Post MD experience in
exclusive Diabetic practice.

Required Previous Experience:

 Endocrinology: The candidate has at least one year post DM experience in a high volume center.
 Diabetology: Three years post MD experience in Diabetic Management.

Special Procedures: Successful completion of an approved, recognized course when such exists, or acceptable,
supervised training in residency, fellowship or other acceptable experience and documentation of competence to
obtain and retain clinical privileges as set forth in Physician guidelines governing the exercise of specific
privileges.

Reappointment/Requirements: Current demonstrated competence and an adequate volume of current

experience with acceptable results in the privileges requested for the past 24 months based on results of quality
assessment/improvement activities and outcomes.

Applicant: Place a check mark in the (R) column for each privilege requested. New applicants must provide
documentation of the number and types of hospital cases during the past 24 months.

(R) =Requested (A) =Recommended as Requested (C) =Recommended with Condition (N) =Not
Recommended
(Note: If Recommendations for clinical privileges include a condition, modification or are not recommended, the
specific condition and reason for the same must be stated on the last pages of this form)

(R) ENDOCRINOLOGY CORE PRIVILEGES (A) (C) (N)

▫ Admit, evaluate, diagnose and provide treatment or consultative services to patients

of all ages except where specifically excluded from practice, with illness, injuries or
▫ ▫ ▫
disorders of the Endocrine or Metabolic systems.

▫ Admit, evaluate, diagnose and treat patients of all ages suffering from Diabetes
mellitus.
▫ ▫ ▫
(R) SPECIAL PROCEDURES (A) (C) (N)
(See Qualifications and/or Specific Criteria)

▫ Interpretation and evaluation of Bone Density Assessment ▫ ▫ ▫

Acknowledgement of Physician:

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 Clinical Privileges in Endocrinology

I have requested only those privileges for which by education, training, current experience and demonstrated
performance. I am qualified to perform and for which I wish to exercise at and I understand that:

 In exercise any clinical privileges granted, I am constrained by Hospital rules and Physician guidelines
applicable generally and any applicable to the particular situations.

 Any restrictions on the clinical privileges granted to me are waived in an emergency situation and in such
situation my actions are governed by the applicable section of the Physician guidelines or related
documents.

Signed:…………………………………………………………………………………… Date:…………………
(Applicant Signature)

Signed:………………………………………………………………………………….
(Departmental Coordinator)

Signed: …………………………………………………………………………………
(Director Medical Services)

Signed: …………………………………………………………………………………
(CEO)

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