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Important Forms:

For current medical staff members who wish to request new clinical privileges, please complete the following:
Request for Increased or New Clinical Privileges
Authorization, Attestation and Release

To Request Moderate Sedation Privileges:
Moderate and Deep Sedation Criteria
Moderate Sedation Study Guide
Moderate Sedation Attestation

To Request Central Line Placement Privileges:
Central Line Placement Criteria
Central Line Attestation

To Request Fluoroscopy Privileges:
Fluoroscopy Criteria
Physician Fluoroscopy Education
Fluoroscopy Attestation

Non-Recurring Observer Forms:
Anyone who will be entering SDNAMC to observe a privileged Medical Staff provider will need to complete the following forms PRIOR to entering the facility and will need to return them to Jennifer Powers in the Medical Staff Office. By signing these forms and completing the required HIPAA test, the approved observer will be allowed to shadow a physician for a maximum of 8 hours. Please notify the Medical Staff Office of the date that the shadowing will occur and to obtain a badge access request form.
Non-Recurring Observation Guidelines-SDH
Non-Recurring Observation Guidelines-HIPAA