Delineation of Privileges in Pediatric Infectious Disease 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the form. Ensure that you print clearly for legibility.
3. In the Qualifications section, provide details about your residency and fellowship training. Make sure to include your current certification status.
4. For Required Previous Experience, attach proof of providing services for at least 24 patients over the past year, unless waived due to recent fellowship completion.
5. In the Special Procedures section, document any relevant courses or training you've completed that pertain to requested procedures.
6. Fill out the Privileges Requested section by checking the appropriate boxes (R, A, C, N) for each privilege you are requesting.
7. Finally, sign and date the acknowledgment section at the bottom of the form before submitting it for review.

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