Approved 4/14/10

NYU Hospitals Center

Physical Medicine and Rehabilitation Application for Delineation of Privileges

Licensed Acupuncturist

Applicant (please print or type) ___ Check here if first application

DELINEATION OF PRIVILEGES - ACUPUNCTURE

Education:

1. Training and graduation from an institute accredited by the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine.

Licensure:

1. A current and valid license to practice acupuncture in the State of New York. 2. A current and valid certification by the National Commission for the Certification of Acupuncture and Oriental Medicine. 3. To be in compliance with all New York State laws governing the practice of acupuncture under Article 160.

Malpractice Insurance:

1. To carry and maintain malpractice insurance in the amount or $1,000,000 per occurrence/$3,000,000 aggregate.

Definitions of Practice: Article 160: section 8211

1. “Profession of acupuncture” is the treating, by means of mechanical, thermal or electrical stimulation effected by the insertion of needles or by the application of heat, pressure or electrical stimulation at a point of combination of points on the surface of the body predetermined on the basis of the theory of the physiological interrelationship of body organs with an associated point or combination of points for diseases, disorders and dysfunctions of the body for the purpose of achieving a therapeutic or prophylactic effect. NYU Medical Center Allied Health Professions Licensed Acupuncturist

Approved 4/14/10

Definitions of Practice: Article 160: section 8211

2. Each acupuncturist licensed pursuant to this article, shall advise each patient as to the importance of consulting with a licensed physician regarding the patient’s condition and shall keep on file with the patient’s records, a form attesting to the patient’s notice of such advise. Such form shall be in duplicate, one copy to be retained by the patient, signed and dated by both the acupuncturist and the patient and shall be prescribed in the following manner: WE, THE UNDERSIGNED, DO AFFIRM THAT (THE PATIENT)(

HAS BEEN ADVISED BY A LICENSED ACUPUNCTURIST)

TO CONSULT A PHYSICIAN REGARDING THE CONDITION OR CONDITIONS FOR WHICH SUCH PATIENT SEEKS ACUPUNCTURE TREATMENT.

Privilege:

1. The Licensed Acupuncturist is designated to provide acupuncture treatment to patients under the above article only with the direct referral of a physician and

is limited to the NYU Langone Medical Center Integrative Musculoskeletal Care program.

Responsibilities - Job Description:

1. To elicit, according to the theory of oriental medicine, a detailed and an accurate medical history, and present a functional diagnosis 2. To enter progress notes, organize and present pertinent (normal and abnormal) data in a manner meaningful to the referring physician or designee. 3. To maintain at all times a clean field, proper hospital hygiene, and properly dispose of all needles into a standard biohazard container. 4. To maintain and present at all times a professional demeanor. 5. Explains the necessity, preparation, nature and anticipated effects of the acupuncture treatment.

Scope of Practice:

1. Neurological Disorders: Pain (postoperative and neuropathic), headache (tension, migraine, clusters), Bell’s palsy, tremors, numbness, tingling, Multiple Sclerosis, Rheumatoid Arthritis, Cerebral Palsy, Guillain Barre Syndrome, rehabilitation from stroke (ischemic, hemorrhagic), aphasia, phantom limb pain, pain from amputation (traumatic, surgical), spinal pain (trauma, post surgical), paralysis, tremors or pain due to traumatic head injury, sciatica, carpal tunnel syndrome, post chemotherapy neuropathy and other neurological disorders as designated by the World Health Organization, and standard medical coverage. NYU Medical Center Allied Health Professions Licensed Acupuncturist

Approved 4/14/10

2. Analgesia, Joint Pain – Arthralgia , in all joints, including the spine and limbs, including but not limited to sprains and strains. 3. Nausea due to chemotherapy, post surgical, pregnancy or standard medical treatment. Indigestion or abdominal pain due to gas accumulation as a post-surgical disorder. 4. Stress and anxiety disorders Privilege approved according to Article 60 for Licensed Acupuncturist AGE COMPETENCIES: A=Adolescent (13-18 yrs)

(check all that apply)

AD= Adult (>18 yrs.)

Certification of Mental and Physical Competency

To the best of my knowledge, I am not suffering from, nor undergoing treatment for any physical or mental condition which impairs my ability to discharge my responsibilities for patient care.

___________________________________________ ___________________ Applicant's Signature Date ___________________________________________ ___________________ Supervising Physician’s Signature Date ___________________________________________ ___________________ Chairman, Department of Rehabilitation Medicine Date