Request for specific privileges



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DEPARTMENT OF SURGERY

SECTION OF DENTISTRY/ORAL SURGERY
REQUEST FOR SPECIFIC PRIVILEGES

GROUP 2
1.00 Maxillofacial and Oral Surgery

1.01 ☐ All Oral and Maxillofacial Surgery, Including

Excision of Lesions

1.02 ☐ Fractures Reduction, with Fixation

1.03 ☐ Hydroxylapatite Synthetic Bone Graft Augmentation

1.04 ☐ Mandibular Staple Operation

1.05 ☐ Implants

1.06 ☐ Orthognatic Surgery

1.07 ☐ Osseointegrated Implant

☐ Other Procedures (List):_______________________

___________________________________________

2.00 Pedodontics

2.01 ☐ Orthodontic Tooth Movement

2.02 ☐ Precious Metal Cast Restorations

2.03 ☐ Apicoectomies

2.04 ☐ Periodontal Surgery - Gingivectomy and Periodontal Flap

2.05 ☐ Frenectomy

2.06 ☐ Extraction of Impacted Primary and Permanent Teeth

2.07 ☐ Extraction of Supernumerary Teeth

2.08 ☐ Surgical Tooth Exposures

2.09 ☐ Removal Prosthetic Treatment

2.10 ☐ X-Rays, Including Full-Mouth Series, Cephalograms, and Panoramic X-Rays

2.11 ☐ Pulp Testing

2.12 ☐ Impressions

2.13 ☐ Adult Prophys (Scaling and Curettage)

2.14 ☐ Child Prophys

2.15 ☐ Topical Fluoride Application

2.16 ☐ Interceptive Orthodontics - Space Maintenance

2.17 ☐ Amalgam and Composite Restorations on Primary and

Permanent Teeth, Including Pin Restorations, and Restorations That Require Indirect Pulp Caps or Direct Pulp Caps

2.18 ☐ Polycarbonate Crowns

2.19 ☐ Stainless Steel Crowns

2.20 ☐ Pulpotomy

2.21 ☐ Endodontic Treatment - Root Canal Therapy on all Primary and Permanent Teeth, Including Host and Core Restorations

2.22 ☐ Extractions of Nonimpacted Primary and Permanent Teeth

2.23 ☐ Therapy Primary/Perm. Teeth, Including Post & Core

Restorations

2.24 ☐ Sealants


2.25 ☐ Bonding

2.26 ☐ Cosmetic Dentistry

2.27 ☐ Non-Surgical Periodontal Therapy

3.00 General Dentistry

☐ General dentists are requested to list the procedures you wish to perform, based on evidence submitted of past training or experience. Operating room privileges may be granted on an individual basis for certain procedures.

4.00 Periodontics

4.01 ☐ Periodontal Surgery

4.02 ☐ Dental Implant Placement

4.03 ☐ Conservative, Non-surgical Periodontal Therapy

5.00 Prosthodontics

5.01 ☐ Crowns

5.02 ☐ Bridges

5.03 ☐ Partial Dentures

5.04 ☐ Complete Dentures






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******************************************************************************

Department:

Reviewed and recommended, as requested:_____


Reviewed and recommended, with exception:_____

Reviewed but not recommended:_____


______________________________________________________________________________

Chairperson Date


Medical Staff Executive Committee:

Reviewed and recommended, as requested:_____


Reviewed and recommended, with exception:_____

Reviewed but not recommended:_____ Date____________________


Board of Hospital Managers:

Reviewed and approved, as recommended:_____


Reviewed and approved, with exception:_____

Reviewed but not approved:_____ Date____________________




Note: If privileges are denied, limited, or granted other than as requested, documentation must be provided.


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