_,,,, Clinical Privileges Update Form Heather Kelly Department of Anesthesiology U:f)UV}~RSI'rY...~fViH.GINIA!ru.u! HEALTH SYSTEM I have reviewed the

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Edwina Grant
5 years ago
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8 _,,,, Clinical Privileges Update Form Heather Kelly Department of Anesthesiology U:f)UV}~RSI'rY...~fViH.GINIA!ru.u! HEALTH SYSTEM I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include snpporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): ~.~... """.~.. "..."-,,.~,,.-,, _..._-,,-- Current Privileges not to be Renewed: * "...,,"--,,_ "'Privileges not renewed are not I'eported as being voluntarily relinquished unless Ihls Is done while you Rre under Investigation; 01', in return for 1I0t conducting nllinvestigntion or pl'oceedlng. Ifpl'lvlleges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be flied with the National Praelitioner Databank. \ Ok ~!IJ~jI3,,~_ ~-E ::...,,-... -,,--m. "_"_.,, "" ""... m"' As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the above~ named clinician's level of experience, past performance and quality indicators (If renewing privileges) as related to requested privileges and agree that the above named clinician's qualiocations are appropriate. Since:4he date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data:. We find D follows: Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review In months. D Should have clinical privileges granted but restrlcte~jl8' ~112-//3 -i/!j-//----ff/0----,/ /~ /" DATE DIVlSIO~[~91!ll LIAISON SiGNATURE 2/1/LJJ--_ "...-.-~..._ b-...,... DATE DEPARTMENT CHAIR SIGNA-rtJRE... ~.-/.+-/_----. novl..d

9 Clinical Privjleges Update Form l1n1versity qrvii~ginia Heather Kelly Department ofanestbesiology 1_ HEALTH SYsrEM 1 have reviewed the privileges previously granted to me and request tbe following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:'" ~:9_,._~._,.._.".".~_,_,.._ _-----,'-.._ Plivllel--;~~~t ~~ ~;Cd~-;n;-~ot r;~i~'i~d '~~~ b~i~ g ~~I~;itR;iiy- reu~q ~I~h~~fw;i~~~ tiiis~i; dolie wblj~ y~u 'R~~' ~~d;~'j~~;iipiion;. or, In return fol' Dot couducting ad Investigation or proceeding. Ifplivileges are to be reported as voluntarily relinqllished YOII will be notified lind receive a eopy or the repol't to be filed with the National Practitioner Databank. _'L<B:flL DATE As tbe Division HeadlQI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (If renewing privileges) as related to requested privileges and agree that the above named clinician's qualitieations are appropriate. Since tbe date of the last appointment, we have reviewed applicable information from the following sources of quatky and utilization data: We find 8$"Jollows: [\2(Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as, requested D Concems noted on review with corrective action plan In place with recommendation of reappoinbnent to the clinical staff with privileges as requested, but subject to a review In months. Should have clinical privileges granted but restricted as f~lluax.,l... o t(p((~. DATE NSIGNATURE D.L. Bogdonoff I /7/ ',- ----_._._--' DATE ""-.-"~----~-~ ~,---,--,,-,,-""-""--,..,,.. ARTMENT CHAIR 8IGNATUREGf~ Rich Revls.d 3IIIl006

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~ ~..._..._...~..._ CLINICIAN SIGNATURE Clinical Privileges Update Form UNlVEHSrry qrvirginiau Barbara Wilson Department of Dermatology L--. HEALTH SYsTEM ~ ~ I have reviewed the privileges previously granted to me and request the following