____________________________________ __________________________ DWHP Section Chief Date (signature - if applicable) APPROVE/DISAPPROVE _____________________________________ __________________________ Date APPROVE/DISAPPROVE _____________________________________ __________________________ Date APPROVE/DISAPPROVE ____________________________________ __________________________ David Stockwell, MHA Date Director VA NORTHERN CALIFORNIA HEALTH CARE SYSTEM (NCHCS) APRN Privilege List Provider’s Name: Location Key: CLC Community Living Center/ Center for Rehabilitation and Extended Care, Martinez – INP Inpatient Sacramento OUT Out Patient Clinics – – TEL Telehealth HBPC Home Based Primary Care OR Operating Room – – – ED Emergency Department UC Urgent Care C&P Compensation and Pension – – – Privilege(s) Following each privilege you select below, indicate the Requested APRN Functions and Procedures settings where you intend to Initials are practice your selected These privileges may be exercised using appropriate required privilege(s) by circling the below for technology and resources in support of Telehealth care. appropriate setting below. each privilege Service you are Chief requesting Initials
____________________________________ __________________________ DWHP Section Chief (signature - if applicable) Date APPROVE/DISAPPROVE _____________________________________ __________________________ Date APPROVE/DISAPPROVE _____________________________________ __________________________ Date APPROVE/DISAPPROVE ____________________________________ __________________________ David Stockwell, MHA Date Director VA NORTHERN CALIFORNIA HEALTH CARE SYSTEM (NCHCS) APRN Privilege List Provider’s Name: Location Key: CLC – Community Living Center/ Center for Rehabilitation and Extended Care, Martinez INP – Inpatient Sacramento OUT – Out Patient Clinics TEL – Telehealth HBPC – Home Based Primary Care OR – Operating Room ED – Emergency Department UC – Urgent Care C&P – Compensation and Pension Privilege(s) Requested APRN Functions and Procedures These privileges may be exercised using appropriate technology and resources in support of Telehealth care. Following each privilege you select below, indicate the settings where you intend to practice your selected privilege(s) by circling the appropriate setting below. Service Chief Initials Initials are required below for each privilege you are requesting
Scope-Practice_Nurse-Prac.docx