Kingdom of Saudi Arabia

‫المملكة العربية السعودية‬

MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

UROLOGY
NAME EMPLOYEE NUMBER:
:
ID NUMBER: YEARS OF EXPERIENCE:
SAUDI COUNCIL REGISTRATION #: DATE OF EXPIRATION:

Designation:

 RESIDENT  SPECIALIST  CONSULTANT

Certification/s:
 BCLS  ACLS  ATLS  PALS  Other/s (please specify)________________

Clinical Privilege Category:

 TEMPORARY  APPROVED  EMERGENCY
At the time of a life-threatening clinical emergency, any Practitioner may render whatever care he/she believes to
be indicated regardless of the extent of his/her granted privileges.

Instructions:
APPLICANT: In the first column below, place a check in the appropriate box whether you have requested for the
privileges listed on the second column.
GENERAL INSTRUCTION: Please tick () in the appropriate column whether the privileges that the applicant
applied for is “GRANTED”, “GRANTED WITH SUPERVISION” or “DENIED”. (If the requested privileges
are either “GRANTED WITH SUPERVISION” or “DENIED”, the “REMARKS” column may be necessary to be
filled up).
Note: A copy of this privilege list will be given to the applicant. The original privilege list will be kept in the
“Personnel File”. The Clinical Privilege of Medical Staffs will be reviewed every 2 years along with their Annual
Evaluation for Contract Renewal or as necessary. (For New Medical Staffs, review of privilege will be after 90
days from the start of employment.)

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION

GENERAL (BASIC) PROCEDURES

MS-001 (2) Page 1 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

UROLOGY
  Admitting Privileges   
Conscious IV
Sedation
    
(May require
Anesthesia approval)

UROLOGY PROCEDURES

BLADDER
  Cystolithotomy   
Percutaneous or open
    
cystostomy
PROSTATE
  Prostatic biopsy   
URETHRA
Meatotomy-
    
meatoplasty

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION

UROLOGY PROCEDURES
TESTES
Radical -
  orchidoectomy/simple   
orchidoectomy
  Hydrocelectomy   
  Testicular biopsy   
Epididymal cyst
    
excision
  Varicocelectomy   
PENIS

MS-001 (2) Page 2 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

UROLOGY
  Penile fracture repair   

OTHER PROCEDURES
BLOOD TRANSFUSION AND INFUSION
Infusion ( IV Fluids,
    
plasma, etc.)
  Intravenous medicines   
Blood transfusion- whole,
    
packed cells

If at any stage you wish to perform any surgical or therapeutic procedure that is not listed in this application, you
must refer to the Credentialing and Privileging Committee.

CLINICAL PRIVILEGES APPROVAL

STAMP &
NAME & DESIGNATION DATE
SIGNATURE

Requested by: ___________________________

Dr. Mohammad Radi

Recommended by:
Head of Urology Department

Approved by:
Dr. Anwer Nehal Ghouri

MS-001 (2) Page 3 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

UROLOGY
Medical Director/
Medical Credentialing & Privileging
Committee Chairman

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 4 of 4