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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