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  • Clinical Privileging Form

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    jirehcounseling
    323 vizualizări1 pagină
    CLINICAL PRIVILEGES: Name Effective from Acknowledgment of Practitioner I have requested only those privileges for which my education, training, current experience and demonstrated performance I am qualified to perform. I understand that in exercising and clinical privileges granted, I am constrained by any Agency and Clinical Staff policies and rules applicable generally and applicable particular situation. Signature and credentials Name and credentials Agency Use Only Conditions / Modifications The requested clinical privelges have been approved by the Board of Directors with the following conditions, or modifications

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    CLINICAL PRIVILEGES: Name Effective from Acknowledgment of Practitioner I have requested only those privileges for which my education, training, current experience and demonstrated performance I am qualified to perform. I understand that in exercising and clinical privileges granted, I am constrained by any Agency and Clinical Staff policies and rules applicable generally and applicable particular situation. Signature and credentials Name and credentials Agency Use Only Conditions / Modifications The requested clinical privelges have been approved by the Board of Directors with the following conditions, or modifications

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca DOC, PDF, TXT sau citiți online pe Scribd
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    323 vizualizări1 pagină

    Clinical Privileging Form

    Încărcat de

    jirehcounseling
    CLINICAL PRIVILEGES: Name Effective from Acknowledgment of Practitioner I have requested only those privileges for which my education, training, current experience and demonstrated performance I am qualified to perform. I understand that in exercising and clinical privileges granted, I am constrained by any Agency and Clinical Staff policies and rules applicable generally and applicable particular situation. Signature and credentials Name and credentials Agency Use Only Conditions / Modifications The requested clinical privelges have been approved by the Board of Directors with the following conditions, or modifications

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca DOC, PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    din 1

    CLINICAL PRIVILEGES

    CLINICAL PRIVILEGES:

    Name Initial
    Reviewed
    Effective from to

    Acknowledgment of Practitioner

    I have requested only those privileges for which my education, training, current experience and
    demonstrated performance I am qualified to perform and for which I wish to exercise at Jireh
    Counseling and Consulting Services, Inc. (JCCS), and;

    I understand that in exercising and clinical privileges granted, I am constrained by any Agency
    and Clinical Staff policies and rules applicable generally and applicable to the particular situation.

    Signature & credentials Date

    Name & credentials

    ****Agency Use Only****

    Conditions/Modifications

    The requested clinical privelges have been approved by the Board of Directors with the following
    conditions, or modifications and the explanation for same.
    Privileges Conditions/Modifications

    Explanation:

    Acknowledgement: The above reflects the final action taken by the Board of Directors of Jireh
    Counseling and Consulting Services, Inc.

    Program Director Date

    BF802- Clinical Privileges Est. Mar 2008

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