Scribd
Upload
510 views

Borang Permohonan Privileging PDF

1) This document is an application form for clinical privileges at a hospital. It requests the applicant's personal details, area of practice, and a list of procedures they are requesting privileges for. 2) The applicant must provide at least two referees familiar with their clinical skills and can include any other relevant information. 3) The head of the applicant's department must review the application and provide a recommendation to approve or not approve the requested privileges, including a reason if not recommending approval. 4) The hospital privileging committee will make the final decision to approve or reject the application, and provide a reason if rejecting it.

Uploaded by

Banizulfaqqar Mozainie
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
510 views

Borang Permohonan Privileging PDF

1) This document is an application form for clinical privileges at a hospital. It requests the applicant's personal details, area of practice, and a list of procedures they are requesting privileges for. 2) The applicant must provide at least two referees familiar with their clinical skills and can include any other relevant information. 3) The head of the applicant's department must review the application and provide a recommendation to approve or not approve the requested privileges, including a reason if not recommending approval. 4) The hospital privileging committee will make the final decision to approve or reject the application, and provide a reason if rejecting it.

Uploaded by

Banizulfaqqar Mozainie
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Priv 1 - (2018)

APPLICATION FORM FOR CLINICAL PRIVILEGES


(Sila sertakan senarai prosedur yang hendak di privileged)

SECTION A : Personal Details


Name :___________________________________________
Identification Card Number :___________________
Area / Discipline / Speciality :___________________
Staff Position : Medical Officer Grade :______ PHOTO
Nurse Grade :______
Assistant Medical Officer Grade :______
Allied Health Professionals Grade :______
Telephone Number : Office :______________Mobile :__________________

Request For Approval Of Privileges


List of Procedure :
1)_______________________________________ 6)_____________________________________
2)_______________________________________ 7)_____________________________________
3)_______________________________________ 8)_____________________________________
4)_______________________________________ 9)_____________________________________
5)_______________________________________ 10)____________________________________

Type Of Request First Application Renewal

I Request Privileges In Core Procedures Specific Procedures

Please List At Least Two Referees Familiar With Your Clinical Skills

Name Position

Name Position

Other information (include any additional information that you wish to bring to the attention of the HPS

Signature Of Applicant :______________________ Date _________________


RECOMMENDATION

As the Head of Department / Designee, I have received the application for the procedure requested.

RECOMMENDATION :

Recommendation

Not recommended

If not recommended, state reason


….………………………………………………………………………………………………………………………………………………………..
….………………………………………………………………………………………………………………………………………………………..
….………………………………………………………………………………………………………………………………………………………..

Signature of Head Of Department / Designee :………………………………


Name :……………………………………………………………………………………………
Date :………………………….

FOR OFFICE USE


HOSPITAL PRIVILEGING COMMITTEE

Application Approved

For Reassessment*

Application Rejected *

* Reason :
….…………………………………………………………………………………………………..
….…………………………………………………………………………………………………..
….…………………………………………………………………………………………………..

Hospital Privileging Committee Chairman :…………………………………… Date :………………………..

You might also like