Fairview Health Services SPONSORED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Professional Practitioner Scope of Practice

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1 Fairview Health Services SPONSORED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Professional Practitioner Scope of Practice PAGE 1 OF 3 Applicant s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity Inpatient/hospital(s) Fairview Maple Grove Medical Center (Ambulatory Care Center) 1, 2 Fairview Maple Grove Ambulatory Surgery Center 1 Fairview Hospital-Based Clinic (such as UMMC Clinics, Fairview Ridges Specialty Clinic for Children, Fairview Southdale Oncology Clinic, Fairview Southdale Hospital Breast Center) 1, 3 Fairview Free-Standing Ambulatory Clinics 1 I need to the following Fairview Entity Box on Privilege Form Individual Fairview hospital(s) University of Minnesota Medical Center, Fairview (UMMC) Fairview Maple Grove Ambulatory Surgery Center (MGASC) Individual Fairview hospital where clinic is affiliated Fairview Group Practice Ambulatory Clinics (FV Clinics) 1 Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to those practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are not otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel. 2 Privileges granted by UMMC can also be exercised at these entities in Maple Grove in accordance with procedures available at the sites. 3 Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with procedures available at the clinic. Education: Licensure: THRESHOLD CRITERIA Applicant must hold a minimum of a Master s Degree from an accredited university in Psychology, Social Work, Counseling, Marriage and Family Therapy, Psychiatric Nursing, or equivalent Behavioral discipline. Applicant must be licensed (certified or registered) in the State of Minnesota in the appropriate specialty. Documentation: Applicant must provide satisfactory documentation of competence for any specialized services they wish to include within their scope of practice. Sponsorship: Applicant must submit a Fairview Allied Health Professional Sponsorship form completed by an LIP at University of Minnesota Medical Center or qualified member of the Medical Staff in good standing at the Fairview entity to which the applicant is applying. The sponsorship form is attached to this privilege form. Z:\common\forms\cvo\Privilege Forms\Mental Health Service Provider-Master s Level.doc Approved: 6/02; 6/09 (new format);9/12; 4/13;6/14

2 PAGE 2 OF 3 Fairview Hospital Entity Codes UMMC - University of Minnesota Medical Center, Fairview FSH - Fairview Southdale Hospital FRH - Fairview Ridges Hospital FNH - Fairview Northland Medical Center FLH - Fairview Lakes Medical Center Fairview Ambulatory Entity Code FV Clinics = Fairview Free-standing Ambulatory Clinics MGASC = Fairview Maple Grove Ambulatory Surgery Center Definitions/Abbreviations Core Privileges - Privileges routinely taught in residency/fellowship programs Special Request Privileges - Privileges not routinely taught in residency/fellowship programs; new technology or procedure; high risk; or requires ongoing practice to maintain competency N/A - Indicates privilege not available at the specific Fairview entity AF - Indicates an additional form is required to request the privilege SUPERVISED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Threshold Criteria Must meet Threshold Criteria listed on page 1 Scope of Practice i The mental health practitioner may treat only patients of sponsoring LIP or qualified Medical staff member as identified above. i Completion of appropriate documentation in accordance with facility standards. PATIENT POPULATIONS Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory UMMC FSH FRH FNH FLH FV Clinics Please identify the patient populations for whom you wish to provide services and that are within your scope of practice based on your training and supervised experience: Children Adolescents Adults Older Adults Medical Patients Mental Health Inpatients Mental Health Outpatients ASSESSMENT SERVICES - ADMINISTRATION ONLY Administration of psychological tests and assessments, assisting in psychological diagnosis in conjunction with a LIP sponsor and, as appropriate, in coordination with multidisciplinary treatment team. ASSESSMENT SERVICES - ADMINISTRATION AND INTERPRETATION Administration and interpretation of psychological instruments, assisting in psychological diagnosis in conjunction with a LIP sponsor and, as appropriate, in coordination with multidisciplinary treatment team. Please check below which, if any, of the following assessment services you wish to provide that are within your scope of practice based on training and/or supervised experience. Each of the assessment services requires specific documentation of training and/or supervised experience in the administration and interpretation of assessment techniques. Forensic assessment Mental Status Examination Objective Personality Assessment Psychoeducational Assessment Intellectual Assessment Neuropsychological Assessment Projective Personality Assessment Vocational Assessment Documentation must be within the last two years and in one or more of the following forms: 1) Letter from a training program attesting to competence for each modality specified. 2) Letter or certificate from a training course for each modality specified. 3) Peer Competency Assessment for Special Request Privileges form completed by a qualified peer attesting to your competency to perform the specific procedure(s). Form is enclosed in application packet; additional copies may be made if necessary. Continued on next page

3 PAGE 3 OF 3 INTERVENTION SERVICES - CORE Provision of psychotherapy using appropriate modalities under the sponsor s supervision and, as appropriate, in coordination with treatment team. INTERVENTION SERVICES - SPECIALIZED Please check below which, if any, of the following specialized services you wish to provide that are within your scope of practice based on your training and/or supervised experience. Each of the specialized services requires specific documentation of training and/or supervised experience. Behavior Modification Hypnosis Pain Management Biofeedback Group Therapy Sex Therapy Couples, Marital, or Family Therapy Documentation must be within the last two years and in one or more of the following forms: 1) Letter from a training program attesting to competence for each modality specified. 2) Letter or certificate from a training course for each modality specified. 3) Peer Competency Assessment for Special Request Privileges form completed by a qualified peer attesting to your competency to perform the specific procedure(s). Form is enclosed in application packet; additional copies may be made if necessary. TELEHEALTH BHP DEC SPONSORED SERVICES Threshold Criteria Education: Applicant must hold a minimum of a Master s Degree from an accredited university in Social Work (MSW), or a Doctorate in Psychology, Education or related field (PhD, EdD). Licensure: Applicant must be licensed (certified or registered) in the State of Minnesota in the appropriate specialty (LICSW or LP). Sponsorship: Applicant must submit a Fairview Allied Health Professional Sponsorship form completed by the BHP Chief Medical Officer. Other: Must be a qualified Behavioral HealthCare DEC Sponsored Provider Core Privileges SCOPE OF PRACTICE: Provides diagnosis and treatment of psychological function, disability, impairment, including addictions and emotional, mental and behavioral disorders, including plans based on a differential diagnosis, via the DEC web based electronic system. *Completed and signed Professional Staff Sponsorship Form Required* Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory UMMC FSH FRH FNH FLH FV Clinics N/A I attest that my professional liability insurance covers the responsibilities listed. Signature

4 PROFESSIONAL STAFF SPONSORSHIP FORM Professional Staff Practitioner s Name Sponsoring Physician s Name: (Sponsoring physician must be a member in good standing of the Medical Staff at the entity(ies) to which the applicant is applying) SPONSORING PHYSICIAN STATEMENT: I support the application of the above named individual for the services requested and agree to all of the terms, conditions and obligations associated with my supervising/sponsoring said individual as specified in the policies and rules of the Fairview entity(ies) to which applicant is applying. Sponsoring Physician Name PLEASE PRINT GROUP PRACTICE SUPERVISION In the event the above named individual for the services requested above will be supervised by several practitioners in a group practice, the group practice (name of group) shall support the application of the above named individual for the services requested and agree to all the terms, conditions and obligations associated with the supervision of said individual as specified in the policies and rules of the Fairview entity(ies) to which the applicant is applying relevant to the individual s practice at the hospital. The group practice promises that any practitioners providing the supervision shall be a member in good standing of the medical staff of the Fairview entity(ies) to which applicant is applying. Officer of Group c:\common\forms\cvo\credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06; 10/10

5 PROFESSIONAL STAFF PERFORMANCE REVIEW FORM Professional Staff Practitioner s Name: Sponsoring Physician s Name: Instructions for Sponsoring Physician: The above-named practitioner has applied for Professional Staff appointment or reappointment at a Fairview entity(ies). Please complete this form to provide an evaluation of the practitioner s current clinical competence. Thank you. 1. Complete each of the criteria below based on demonstrated performance compared to that reasonably expected of a Professional Staff at his/her level of training, experience, and background. A = Acceptable, U = Unacceptable, N.O. = Not observed. CRITERIA A U N.O. COMMENTS Basic job knowledge, competence and skill Service orientation Ethical conduct/hipaa compliance Professional judgment Cooperativeness, ability to work with others Sense of responsibility (work timely, meet professional standards, completion of responsibilities, responsiveness to supervision) 2. The practitioner is capable of performing duties within the scope of his/her services as listed on the scope of practice. (If no, please comment below) 3. Is the overall quality of the patient care provided by the practitioner appropriate and acceptable? (If no, please comment below) Yes Yes No No Comments: RECOMMENDATION: Recommend Recommend with the following reservation(s) Do not recommend (please provide explanation in comment section) Sponsoring Physician Name PLEASE PRINT Return completed form to: c:\common\forms\cvo\credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06 Fairview System Credentialing Office 2344 Energy Park Dr, Ste 127 St Paul, MN 55108