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7 <.Heather AHP Clinical Privileges Update Form Payne Department of OB/GYN aave reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): rj/a ~ Current Privileges not to be renewed: * ~AJo rj/a No *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. -2l'~ \1--'---'\ 0 ~Q~~~------~-- Practitioner's SignatJre As the Supervising Physician/QI LiaisonlDepartment Chair/ Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last -~''}pointment, we have reviewed applicable information from the following sources of quality and ufilization data: Et" Record Review ~ Continuing Education Conferences B""Yhysical & Mental Health related to Job Performance [3""" JYsk Management Events/Quality Management Reports for claims Annual Evaluation D Student Evaluation o Annual Review by Dept. Chair or SCA C3-1>rescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ~ We find as follows: ~eptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges grj.~o as requested, '--!.:~P~;~~;~2re but subject to a review in months. Nancy A. McLaren, M.D. f 1'Z-/pJ ~ ~, Da Ising Physician Signature Katherine w. Kent, M.D. Alternate Supervising Physician Signature,:""--~---. ate ~ I~ Irl) Alternate Supervising Physicia.Signature ~'0. Printed Name Shelia Smith, Associate Chief Chair/RPC Director Signature (for HSF employees) revised 3/1/2005

8 AHP Clinical Privileges Update Form Heather Payne Department of Obstetrics & Gynecology. have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): I '. J~~~~~~O~V_~_f- ~ -:rvn.piq4)on cln~aiq)i');';' C- -- +rai vier) as _ *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. ---'"L-J<& l2mj=-j"6.::..l. _. Practitioner's Signature As the Supervising Physician/QI LiaisonJDepartment Chair/ Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ~"\ppointment, we have reviewed applicable information from the following sources of quality and utilization data: r:r- Record Review ~ Annual Evaluation B:'i~ Continuing Education Conferences 0 Student Evaluation Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA Risk Management Events/Quality Management Reports for claims ~rescriptive Other Privileges (8 hours continuing education documentation required every 2 years) _ We find as follows: ~eptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on revie~ with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a review in months. ~\UI02 q U:708 Dale Nancy McLaren, MD Katerine Kent. MD Alternate Supervising Physician Signature LJ III _cru..~ Alternate Sup~~sing Physician Signature l_o..::::...g_ Terry Lucas Clinical C. Svcs Administrator (for Me employees) Chair/RPC Director Signature (for HSFemployees) revised

9 AHP Clinical Privileges Update Form t-/eo.ik,!&;{~ Department of { RJllbl?h (4S= < ">, have reviewed the pr vileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * I *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. ~dpot4~ Practitioner's Signature As the Supervising Physician/QI LiaisonlDepartment Chair/ Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ~'\ppointment, we have reviewed applicable information from the following sources of quality and utilization data: d5j. Record Review ~ Continuing Education Conferences ~ Physical & Mental Health related to Job Performance 1i?J. Risk Management Events/Quality Management Reports for claims ~ Prescriptive Other Privileges (8 hours continuing education documentation required every 2 years) [J&J o o Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA _ We find as follows:. ~ Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a review in months. ~. 1 (Y'<-La~- () pervising Physician Signature rjanc'a printed~ N1~G.><..:~~:;;::..:...>:.:..i-/---) to/fit 10 r, I l MP~ _kcjhoone, K-eo±_ , /() 116/ Ob Alternate Supervising PhysiCian Signatu~ ",2'0. H.s,.J Clinical C Svcs Administrator (for Me employees) Chair/RPC Director Signature (for HSFemployees) revised 3/1/2005

10 AHP Clinical Privileges Update Form ~~~~L-~~~~~U-~~ Departmentof I have reviewed the pri. ges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current' Privileges not to be renewed: * No *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank. 4il \ct1 :11/Q a! /'I),fl _ Practitioner's Sign~ As the Supervising Physician!QI Liaison/Department Chairl Director! Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance and quality indicators (if renewing privileges) as r~ted to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ')intment, we have reviewed applicable information from the following sources of quality and utilization data: ::,r Record Review Annual Evaluation [gj'continuing Education Conferences 0 Student Evaluation [3' Physical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA o Risk Management Events/Quality Management Reports for claims ~ Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Oilier _ We find as follows: ~~cceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a review in months. qgq.?! 'l1~q;;en~ p~c':f:;:u~ tl/1-_~/t7i X j6d'?vt t1/lb~ Alternate Supervising Physician Signature N~n~~M~G L ~~~~ J<{l.l1~~,fre W Ktt_"i_f_' _ Alternate Supervising Physician Signature?"''''''''' /,1r41~j2. ~/H C air/ Director Signature (for HSFemployees)

11 AHP Clinical Privileges Update Form, L-'-1eo-~t1M_~G'---m_a l_--department of ---reitj fk~/i-h &tji;j I have reviewed the privileges pr iously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): r I. u..-n~ ~. ::r hc\v0 C)\vI~CcJ ~ \"0 cut Q( \'b& -t'olk)vjiy)~j $~tf\s'i:li?-of~. G- CJ~ :~;8~~~cvd~~JjraJtJO~~)~S~ 1')00 v I n - 'c.d\ X. ~ YBa±~ J:.~~ I Ccillu::krrycd\l,) ~ i'v')\'()vl()5cof»i G <t \J oj. - B c-eas+ ths C4')~ Current Privileges not to be renewed: *.J *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank.. :1)4. ~ev::o AHP Signature ~upervising As the PhysicianlQI Liaison/ Department Chair/ Director/ Service Center Administrator, we have -viewed the above-named HCP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named HCP's qualitications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: / Record Review Hep's Health and Mental Status Continuing Education Conferences Sentinel Events/Risk Management Reports o We find ~ follows: ~ Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges as requested, but subject to a review in months. ~/l\~i~d~~ ~e,0131 left....!.\.::...6~\o?.. ' Collaborating Physician Signature Revised

12 .... Privilege List for: Obstetric/Gynecologic Nurse Practitioner.r=>; I-Mar-02 : PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN MIlCH YOU DO NOT REGULARLY PRACTICE. AREAS IN WInCH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO CATEGORY, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE: A B C D The applicant will not undertake patient management except in emergency. The applicant will manage patients with physician present. The applicant will manage patients in collaboration and/or consultation with the physician. The applicant will manage patients as an independent clinician function. ~rocedure :ocedure ~'1:edical.'rocedure Immunization Med Dif Dx & Tx Sexual Counseling Anesthesia Anesthesia PAP Smear Local Regional Fetal Monitoring Doppler studies IncisionIDrainage Anoscopy of Abscesses.Norplant Insertion & Removal Biopsy - Endometrial Biopsy - Vulvar Cryotherapy Foreign Body Removal - Vagina Wound Mgt - Debridement IUD Insertion & Removal Pessary Insertion & Removal Pain Management History and Physical Dx, Assessment Telephone Hospital Patient Admissions Order Order Order- & Mgt Triage/Consultation Rounds Education - Labs (with MD collaboration) - Radiographs EEG Order - Urodynamic Studies Order-ECG Order - Echocardiogram Order - Holter Monitoring Order Order Consults Medications Contraceptive Health Maintenance Counseling Lab Test - Dipstick Urinalysis Lab Test - Vaginal Lab Test - Cervical & Disease Prevention Cultures Cultures Lab Test - Rectal Cultures Neonatal Ped Adol Adult Geriatric (I (l I n (1 o (' A c_ A "1 r".j t,.. (\.J ('~ (l 1) D (l e~ ~ (1 f' (1, r (t c. D D o rr~ (I Page 1 of 3

13 ~ocedure ocedure t'rocedure ' '-~'edical _rocedure ' Lab Test - Soft Tissue Site Cultures Lab Test - Blood Cultures - Draw Surgical Assist Surgical Drain Removal Endocrine/Metabolic Dif Dx & Tx. NST Evaluateation OB - Routine Prenatal & Postpart Eval & Mgt OB - Intermed. Risk Prenatal & Postpart Eval & Mgt OB - High Risk Prenatal & Postpart Eval & Mgt Cardiac Arrest - Assist Colposcopy - Cervical BiopsylECC l Condyloma Tx's Diaphragm Fitting Microscope Eval - Urine Microscope Eval- Vaginal Secretions Microscope Eval - Post Coital Cervical Mucous Microscope Eval - Amniotic Fluid Microscope Eval - Breast Discharge. - _. Intermittent Catheterization Tx Ultrasound - Fetal Ltd - Fetal Presentation Ultrasound - Fetal Ltd - Fetal Cardiac Activity Ultrasound - Fetal Ltd - Dating 1st Trimester Ultrasound - Fetal Ltd - AFI Urodynamic Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Percutaneous EMG Biophysical Profile Evaluateation Lab Test - Throat Cultures Authorized to Prescribe Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate - Urodynamic Studies Neonatal Ped Adol Adult Geriatric (I c, o {1 ~ r c, 0.1 (' (l~ c~ r I C- (' C\ 7i (t (I e, ~ g(i. R c. p..,, p.,' Page 2 of 3

14 OTHER PlUVlLEGES NCODlilaI Pcd Adol Adult Gerhark As the Collaboraneg Physician and Dcpnrtmcnt ChllirlServlce Center Administrator, we have reviewed the abovenamed practltloner'e level or experience, past perlormance nnd quality lndlcators (11'~newing privileges) as n:lnted to requested prtvlleges and agree thnt the above: d actltlol1cl's qwdiflcations arc appropriate. \ JIG; DATE"-. 11 et/~o-,-l- _ DATI!: ~ p t1tn t~_n6j'\~ Name Prlnlrrl A1tu!Ultc Sup~rvj~ing Physlc:J.lI SlgIUl/url! N.m": Pr1n~i! tj\. 'M t.~_~ D';'T. Alternate Supervl.it111 Plly~lclnn SIJ(aAWrc N,uz", PrInked DllpL Ch4lr (ITSvo: Center AdminflftrlJtor N~e PrJnltd. Page ~or 3

UNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To

UNMH Family Medicine Clinical Privileges. Name: Effective Dates: From To All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective April 28, 2017: Initial Privileges (initial appointment) Renewal of Privileges (reappointment)