Sign In
Skip to main content Open accessibility information page

State Board of Medical Examiners

Alternative Privilege Process

An application for alternative privileges consists of a general section and a specialty specific section. To review the application process, a licensee can access application forms and Frequently Asked Questions (FAQ) on this site. To ask questions, a licensee can contact the alternative privileges e-mail address. (An alternative privileges telephone number will be available starting September 8, 2003 through December 26, 2003.)

Because the regulation provides for the delegation of the initial review of applications to an outside reviewing entity selected by the Board, certain details of the application process, including the use of electronic application submissions, are being finalized at this time. Nonetheless, certain basic steps are expected to remain the same and are summarized below.

To initiate the application process, a licensee will request the application by e-mail (or after September 9, 2003 by telephone) providing name, office telephone number, license number, address of record and the specialty area of the requested procedure(s). A licensee who requests application materials will receive the general section of the application (with certain identifying information from the licensee's file already included) and the specialty section of the application. There is a separate application section for each specialty. These specialty sections can be downloaded from links below. A partial electronic application, with some sections which can be completed on line, is expected to be added to the process later in the fall.

The specialty sections of the application contain the specific training required, the procedures for which alternative privileges are needed and any additional training which may be necessary. The application identifies several attachments which must accompany required information such as references, completed training and experience. These attachments vary to some degree with the specific procedures being requested; however certain attachments are needed for any alternative privileges requested. Forms for the attachments are now available in pdf files for applicant review.

Prospective applicants for alternative privileges are those practitioners who do not hold hospital privileges. Practitioners who hold hospital privileges for the procedures they perform or wish to perform in an office setting do not need alternative privileges for those procedures.

Specialties and Included Procedures in Each

For a list of procedures in each specialty for which alternative privileges are required, click here (Table of Specialties) then click on the specific specialty.

Specialties and the Procedures In Each Requiring Additional Training

For a list of procedures within each specialty that require additional training, and for identification of the type of additional training that is required, click here (Table of Specialties/Additional Training) and then click on the specific specialty.

Application - General Section

An application for alternative privileges consists of a general section which will be provided to every applicant, regardless of specialty. The general section of the application will contain preprinted information including the specific applicant's name and certain other identifying information. It will be sent from the Board of Medical Examiners to the applicant following receipt of the applicant's request for an application package. The Application general section (to be completed for every applicant, regardless of specialty or anesthesia service) is posted here.

In every application also seeking privileges in surgery or special procedures, the application will include an anesthesia services section and the specific surgery or special procedures sections. The general section of the application requires only confirmation of the basic licensee preprinted identification information and completion of the information concerning hospital privileges.

Application - Specialty Specific Sections

If a practitioner DOES NOT HAVE hospital privileges to administer or supervise the administration of anesthesia services or to perform surgery or special procedures, then the practitioner must obtain alternative privileges. To obtain alternative privileges, a licensed practitioner must submit an application. The term "anesthesia services" is defined in the regulation and means conscious sedation, regional anesthesia or general anesthesia.

The surgery or special procedures a practitioner performs or intends to begin performing and the anesthesia services which a practitioner administers or of which the applicant supervises the administration in the office setting will determine the specific alternative privileges the licensed practitioner needs. Procedures requiring privileges and privileges requiring additional training are identified in each specialty specific application.

Specialty Specific Sections of Applications

Click on the specialty to see the application for alternative privileges for procedures in that specialty.

Specialties Applications
Anesthesia Otolaryngology - Head and Neck / Facial Plastic Surgery
Conscious Sedation Plastic and Reconstructive Surgery
Dermatology Psychiatry
General Surgery Radiological Procedures Requiring Anesthesia Services
Medical/Pediatric Subspecialty Services Requiring Anesthesia Services Thoracic Surgery
Obstetrics and Gynecology Vascular Surgery
Ophthalmology Urology
Orthopedics Podiatric Surgery

Clinical Experience

The application for alternative privileges requires that applicants submit evidence of clinical experience by attestation of the number of procedures performed (anesthesia attestation, conscious sedation attestation, surgery/special procedures attestation) and demonstrate proof of competence through the submission of references from three individuals who have observed their practice within the two years preceding the application. If additional training is required, one reference must address that training. (reference 3A) In addition, applicants must submit logs of all the cases involving the requested anesthesia services, surgery or special procedures done in the relevant field in the office or ambulatory care facility during the two years preceding the application.

Practitioners who will be applying for any alternative privileges are strongly encouraged immediately to start compiling the information necessary to complete the forms for the log of surgery, special procedures and general or regional anesthesia and the log for conscious sedation.

Log Forms

The log is a record of patients who received anesthesia services, surgery or special procedures administered or performed by the practitioner during the two years before the date of the application for alternative privileges. The log is to include complications related to the anesthesia services or surgery/special procedures performed in an office setting or licensed ambulatory care facility setting.

There are three versions of the log form, depending upon the alternative privileges requested.

The first log form is for the list of patients who received general or regional anesthesia. The second log form is for the list of patients who received surgery or special procedures. The log format works best if practitioners who are applying for alternative privileges to perform more than one surgical or special procedure complete a separate Attachment 4A log sheet for each different procedure. The third log form is slightly different because it does not require a list of all patients who received conscious sedation. The conscious sedation log is for a list of only those patients who received conscious sedation and experienced complications.

Patient names related to the information contained in the log must be kept confidential and so they are not to be used in the log. Instead of names, a number (or other code the applicant chooses) should be substituted for the name. So that the patient can be identified, the applicant shall maintain a corresponding list of the name and number (or coding) as a means to identify the actual patient, from the number included in the log. In connection with provision of other patient records, patient names and other patient personal identifying data throughout the application process must be redacted ( blocked out, crossed out or deleted) from the copies submitted in the application process.


Evidence of required training in the specialty is required and for those procedures requiring additional training, further documentation is necessary. Generally that evidence can be supplied through the submission of documentation establishing certification granted by a certifying entity recognized by the American Board of Medical Specialties or the American Osteopathic Association or another certifying entity of comparable scope and rigor. A third track is available if the applicant is able to provide proof of certification in another field and active participation in the examination process leading towards certification in the field in which privileges are requested. Each specialty specific application details the appropriate training and additional training documentation to be provided.

Answers to Frequently Asked Questions

Answers to Frequently Asked Questions provide additional information and will be updated on a regular basis throughout the fall. By mid-October, the Board expects that practitioners will be able to complete most of the application process on line, with outside documentation to be provided in hard copy.

Last Modified: 7/7/2015 9:27 AM