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1 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 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:* ~---~ ~*Privileges not renewed are not reported 8S being voluntarily relinquished unless this i~'do'~;";'hile you are under in~estigation; lor, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you jwill be notified and receive a copy of the report to be filed with the National Practitioner Databank. DATE ~ 0/( ~ ~..._..._...~......_ CLINICIAN SIGNATURE As the Division Head/QI 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 qualifications are appropriate. Since I'e date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data:. We find as 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. Should have clinical privileges granted but restricted as followsi'1'...-- Revised 311{2006
2 UVA Medical Center, UVA Transitional Care Hospital & UVA Health South Rehabilitation Hospital Request for Laser Privileges artment of Dermatolo Division of : Ph sician Name: Barbara Wilson, M.D. Please check those types of lasers that you are requesting privileges for, and indicate type oftraining/experience. TYPE OF EXPERIENCE: 1 Completed Formal Training 2 Limited Experience - without formal training 3 Extensive Experience without formal training PRIVILEGES Laser Privileges Requested Type of Experience Laser Surgery - Argon Laser Surgery - CO2 Laser Surgery - Diode Laser Surgery Dye Laser Surgery - Excimer.. Laser Surgery - Holmium " Laser Surgery - KTP Laser Surgery - Nd: Yag 7A t) Laser Surgery Pulse Dye V L~ q, -/ 7~.IU/l1 /J y{ :I) (/ Laser Surgery - Tunable Dye / I 7 Clinician's Signature As Division Head/QI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree that the clinician's qualifications are appropriate. l ' tr::j U,I> XY1\V1Lldb~1Uo1'C,;i;n r-l<jal Date ~ (ll ~ ~Partrl#11tChair.. Please return completed form to Clinical Staff Office, Box Rev 11/2012
3 I ~ Clinical Privileges Update Form! U..NtVERSny I..,?VIRGINIA ', Barbara Wilson Department of Dennatoiogy HEALTH SVs:n!:M I I have reviewed the privileges previously granted to me and request tbe following changes to Include any new tberapies, 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:'" ~ Fpri;jkP-not-;;;;;;i;~..;;;t;;(wrted~; beidl OluDtllrl.ynll~umh;duftienthl'itdone-;itHe~yoo I;;-;ud; In;e;iiptk,"i;- jor, III retan tim' liot eoodudlag lin illye8tiption or proeeedillg. ItprlvUqes are to be "POrted al volunurlly relinquished you \11'01 be IIOtifled alld rettive a copy otthe report to be filed with the National Practitioner Daubank. As the Division Head/QI Liaison and Department Chair/Medical Dlredor, we have review~d the abovenamed clinician's level ofexperience, past performance and quality indicators (If renewing privileges) as related to requested privileges and agree tbat the above named clinician's qualifications are appropriate. Stnce the date olthe last appointment, we have reviewed applicable Information from the following sources of quality and utilization data:. We find.(follows: [0'~cePtable review with recommendation of reappointment to the clinical staff with clinical privileges.. requested Concerns noted on review with corrective action plan In place with recommendation of reappointment to the clinlcal.taff with privileges as requested, but subject to a review in monthe. _lied 311rJ11et
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Clinical Privileges Update Form Kenneth Liu Department of. Radiology I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
Clinical Privileges Update Form
Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
., Clinical Privileges Update Form Susan Modesitt Department of Obstetrics and I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,
q' Clinical Privileges Update Form U~lVERSTY '!VRGNA Bhiken Naik Department of Anesthesiology HEALTH SYsTEM have reviewed the privileges previously granted to me and request the following changes to include
.0 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as. Clinical Privileges Update Form
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