8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae!
ORTHOPEDICS SURGERY
I hereby request surgical privileges in the specialty of Orthopaedics as shown in
this form. I understand that privileges granted are subject to a bi-annual review
coinciding with reapplication for medical staff membership. I also understand
that application for additional or new procedures can be made at any time with
proper documentation.
Please indicate with an X in the appropriate bo! and by signature at the end of
this document the procedures you are requesting privileges for.
"pplied for "pproved
"mputations of disarticulations of digits #$% &O
"pplication of plaster or synthetic splints and casts #$% &O
"rthoroscopic surgery #$% &O
"rthrodesis- various joints #$% &O
"rthrography of various joints #$% &O
"spiration and'or injection of joints( bursae( cysts-
local anesthetics( cortisone derivatives( etc.
#$% &O
)iopsy( bone or soft tissue- incisional or needle #$% &O
)one drilling operation #$% &O
)one grafting procedures for various indications #$% &O
*losed or open reduction of fractures and dislocations of
the e!tremities
#$% &O
+ebridements or repair of wounds of head( nec, and
e!tremities
#$% &O
+ecompression of nerve( tendon( or soft tissue #$% &O
+iagnostic arthroscopy #$% &O
$piphyseal arrest or stimulation #$% &O
$!cision of bursae( ganglions( or cyst #$% &O
$!cision of tumors( calcium deposits neuromas( or other
masses from soft tissue and bone of e!tremities
#$% &O
-asciotomy and fascietomy #$% &O
Incision( drainage( and closed irrigation acute or
chronic infectious processes in e!tremities
#$% &O
Insertion of e!ternal s,eletal fi!ation and traction #$% &O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae!
devices .%teinman Pins( /offman( /alo( etc.0
Internal fi!ation of fractures of the e!tremities #$% &O
1ocal s,in flaps #$% &O
Ostectomy- partial or complete .i.e.2 distal ulna( carpal
or tarsal bones0
#$% &O
Ostetomies various bones- correction of deformity(
shortening( lengthening( etc.
#$% &O
Partial or total replacement arthroplasties such as
fingers( toes
#$% &O
3ealignment procedure of foot or hand .i.e.2
bunionectomies( pollici4ation( etc.0
#$% &O
3econstruction of ligaments and joint stabili4ation
procedures
#$% &O
3econstructive arthroplasty- various joints of
e!tremities
#$% &O
3emoval of foreign or loss bodies in e!tremities( bac,(
and nec,
#$% &O
3epair of acute or old ruptures of ligaments #$% &O
3epair of acute or recurrent capsular joint injuries
.i.e.2 )an,art( "* joint repair0
#$% &O
3epair of non-union of bone with reduction( fi!ation(
grafting electrical stimulation( etc.
#$% &O
3epair( transplant( or lysis of peripheral nerve #$% &O
%,in grafts and tunnel procedures of e!tremities #$% &O
%ynovectomy of various joints #$% &O
5endon fi!ation( suture( transplant( or transfer #$% &O
Radiography Use of Modality & iterpretatio of i!ages
"therape#ti$ ad diagosti$%
#$% &O
Ultraso#d Use of Modality & iterpretatio of i!ages
"therape#ti$ ad diagosti$%
#$% &O
&l#oros$opy Use of Modality 'ith State (i$ese &
iterpretatio of i!ages "therape#ti$ ad diagosti$0
#$% &O
(o$al aesthesia #$% &O
Cos$io#s Sedatio #$% &O
S#per)isio of Cos$io#s Sedatio Traied Registered #$% &O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae!
*#rse
O5/$3% &O5 1I%5$+
#$% &O
#$% &O
#$% &O

%ignature of "pplicant +ate

%ignature of 6I committee chairperson +ate recommended

%ignature of 7overning )ody chairperson +ate recommended