Download Privilege request form

Privilege request form
Sports medicine
In order to be eligible to request clinical privileges in sports medicine, an applicant must meet the
following minimum threshold criteria:

Basic education: MD or DO

Minimum formal training: Applicants must have successfully completed an ACGME/AOAaccredited residency program in a specialty such as family practice, emergency medicine,
internal medicine, pediatrics, physical medicine and rehabilitation, or orthopedic surgery.
Applicants also must have completed an accredited training program in sports medicine.

Required previous experience: Applicants must be able to demonstrate that they have
successfully performed at least 50 sports medicine procedures in the past 12 months.

References: A letter of reference must come from the director of the applicant’s sports medicine
training program. Or a letter of reference regarding competence must come from the chief of
sports medicine at the institution where the applicant most recently practiced.

Core privileges: Core privileges in sports medicine include but are not limited to the following:
 Prevention, diagnosis, treatment, management, and disposition of common sports
injuries and illnesses
 Emergency assessment and care of acutely injured athletes
 Management of medical problems in the athlete
 Rehabilitation of the ill or injured athlete
 Proper preparation for safe return to participation after an illness or injury
 Integration of medical expertise with other healthcare providers, including medical
specialists, athletic trainers and allied health professionals
 Providing appropriate education and counseling regarding nutrition, strength and
conditioning, ergogenic aids, substance abuse, and other medical problems that could
affect the athlete
 Understanding pharmacology and effects of therapeutic, performance-enhancing, and
mood-altering drugs
 Promotion of physical fitness and healthy lifestyles

Reappointment: Reappointment should be based on unbiased, objective results of care
according to the organization’s existing quality assurance mechanisms.
Applicants must be able to demonstrate that they have maintained competence by showing evidence
that they have performed at least 50 sports medicine procedures annually over the reappointment cycle.
In addition, continuing education related to sports medicine should be required.
I understand that by making this request I am bound by the applicable bylaws or policies of the
hospital, and hereby stipulate that I meet the minimum threshold criteria for this request.
Physician’s signature:___________________________________
Typed or printed name:__________________________________
Date:___ _____________________________________________