TABLE OF CONTENTS PAGE
1. GENERAL.......................................................................................................................... 1 1. A. DEFINITIONS......................................................................................................... 1 1. B. TIME LIMITS......................................................................................................... 2 1. C. DELEGATION OF FUNCTIONS.......................................................................... 2 1. D. CONFIDENTIALITY AND PEER REVIEW PROTECTION............................... 2 1. E. SUBSTANTIAL COMPLIANCE........................................................................... 3
2. QUALIFICATIONS, CONDITIONS, AND RESPONSIBILITIES............................. 4 2. A. QUALIFICATIONS................................................................................................ 4
2. A. 1. Threshold Eligibility Criteria....................................................................... 4 2. A. 2. Process for Waiver of Threshold Eligibility Criteria................................... 7 2. A. 3. Factors for Evaluation.................................................................................. 8 2. A. 4. Burden of Providing Information................................................................. 9
2. B. GENERAL CONDITIONS OF APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES........................................ 11
2. B. 1. Basic Responsibilities and Requirements.................................................. 11 2. B. 2. Immunity and Authorization to Obtain and Release Information............. 12
3. PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES...................... 15 3. A. APPLICATION..................................................................................................... 15
3. A. 1. Application Form....................................................................................... 15 3. A. 2. Misstatements and Omissions.................................................................... 16
3. B. PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES................. 17
3. B. 1. Application Process................................................................................... 17 3. B. 2. Initial Review of Application..................................................................... 17 3. B. 3. Steps to Be Followed for Initial Applicants............................................... 17 3. B. 4. Department / Section Chief Procedure........................................................ 18 3. B. 5. Credentials Committee Procedure............................................................. 18 3. B. 6. Medical Executive Committee Recommendation..................................... 19
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