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30 AHPClinical Privileges Update Form Carolyn Brady Department of Heart Center/Cardiology Clinic I 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): Current Privileges not to be renewed: * *Privileges not renewed are not reported as being voluntarily relinquished unless tbis 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. Date As the Supervising Physician/QI Liaison/Department ChairlMedi, al Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, pas,rmanceand 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 -appointment, we have reviewed applicable information from the following sources of quality and utilization data: Record Review', ~ontinuing Education Conferences " &(...P1lysical&Mental Health related to Job Performance Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA iflusk Management Events/Quality Management Reports for claims ~rescriptive Privileges (8 hours continuing education documentation required every 2 years) Other --~~ ~ ~----~ ~ We find as follows: ~ceptable 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/t"lj Date James Bergin. M.D. Printed Name. ing Physician Signature rinte me 3o.%tclee.~ K~'tcdt Printed Name" MP' Date Alternate Supervising PhysiCian Signature Printed Name ~~--S' Date Clinia,I Care svcs~, rata (for Me em:'oyees) Printed Name Robert M. Strieter. M.D. Date CitaTrlRPCMediCaIDirector Signature (for HSF employees) Printed Name revised 3/1/2005 I,/tah

31 AHP Clinical Privileges Update Form Carolyn Brady Department of Medicine- Cardiology -,---..,, ave reviewed the privilege~ previously granted (copy attached) to me and request the following changes: New 'Piivilegesto be Added (please, indicate category level and type of experience): Cnrrent Privileges not toj)erenewed: *. -..., *~.ivileges,not reil~ly~~r~.f(l,il~tr,~~~.~(l.~ll~. beiil~yolunta.rilyrelin.quished unless this is done.while youare under..inyestigat~~n; 9K,in ' ii retljrilj~! not cond'octirii(:tii)n e,s'tig~ii9n:o~..pt.oc.eeding,i-ifprivilege~are to be reported as voluntarily relinquished you,will'be notified and receive a copy of the report-to be fllehwith the-national Practitioner Databank. Date As the. Supervising. Phy*ia~LQl~iai~on/DepartmentChairlMe, c'al m~ector/ Service Center Administl'at9r,:~e" have reviewed the above;-ihmle~:~tjl?:s level of experience, past performance and quality indicators (iften~wil1g privit 'ges).,as related to requestedpti",i{,egesa,ndagreethatthe above namedahp's qualifications are appropriate: Since the date ()fthelast -"""'ointment, we,have.i:llvie~mappjicable information from the following sources of quality and utilization-data: :.~. -,~--:.',!.:':,"', - -: :. ~.,' ',' A,'C'-: ',,y,:,,;,;,\.>.... Record]{e~ie'\V/ '<.' Annual Evaluation ~ Contiri.uirtg'Edu~a.tf0It:Q6nfetenGes " 0 Student Evaluation ~ Physical & Mental;Ii ~ltii~relatedto Job' Perforrilan~e 0 Annual Review by Dept. Chair or SCA Iilj RiskManagemen!Events/QualityManagement Reports for claims. I J Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ' We findasfollowsr-. 'AccePt~bJe revlewwlth recommetidattorr ofreappotntment with clinicalprivueges as requested. ~ ' '.,' '., o Concernsnoted,qq\reYl.eW,witl:l~ortectiveacticm plan in.place with recommendation of reappolrrtment With privileges as,requested,bli{s~p)~duo areview'in_,_ months. ' (~/(r/~, ~~. '. bate Pririlar}o"S '. 'l&jj;;gphysician Signature /~~' ~... ~' '~'fi[4~~~s-:--ig-na-tur~e-~ Prmted NaTe. ;. Printed JIIaJffe Date, AI~(lr'nate ~upel'vising PhysiciCln Signature 1" "".,;:'.,:.,'.'-,' \' " Dati!- IZ/ft~( Printed Name Printed Name ;ae~1-)(... SIv I~I-~r;ft-ta" Printed Name revised 3/112005

32 AHP Clinical Privileges Update Form Carolyn Brady, Department of Medicine- Cardiology ---,.have reviewed the privileges previously granted (copy attached) to me and request the following changes:,ew Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *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. Date 12-/tl /0 ~ As the Supervising PhysicianfQI LiaisonlDepartment ChairiMe cal 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.appointment, we have reviewed applicable information from the following sources of quality and utilization data: '..,. 1 Record Review o Continuing Education Conferences. lit' Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims 10 Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Oilicr - t6' o o Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA We find as follows: 'Acceptable review with rec~mmendation of reappointment with clinical privileges as request'ed. 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. t2-!f.!crr-.. ~~. op~ Date Primary S ~g Physician Signature Signature Printed Name V\I\. J) Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date - /z/f14( Date Printed Name J2,~#",L?(Ski 'e,klj Mc1 Printed Name revised 3/1/2005

33 I have reviewed the privileges r tviously granted (copy attached) to me and request the following cha ~ few Privileges to be Added (pi indicate category level and type of experience): Current Privileges not to be renewed: * *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. Date Practitio As the Supervising Physician/QI Liaison/Department Chair edical 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: Lf Record Review V' Continuing Education Conferences. U::;Y--Physical& Mental Health related to Job Performance W Risk Management Events/Quality Management Reports for claims [Q/Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other W Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA We find as follows: [9/'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. &//-0 ~~ ~ Date Primary Supervising-Physician Signature (g I\> l Of --:-:--U_Gtu---t '"---T-Xt Date Altern-ate SupWsmg PhYSICian Signature Printed Name 36~~ ~~~ Printed Name so Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physiclan Signature Printed Name Clinical Care Svcs Administrator (for Me employees) Printed Name 4 rj)~b rinted Nam " t?obcv-:- t H Shi e~evised 3/1/2005

34 Privilege List for: Acute Care Nurse Practitioner lo-apr-07 Name: Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRNILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A B C Theapplicantwillnotundertakepatientmanagementexceptin emergency. The applicant will manage patients with physician present. Theapplicantwillmanagepatientsincollaborationand/orconsultationwiththephysician "'rocedure.trocedure Adjust Cardiac Assist Devices Adjust Intra-Aortic Balloon Pump Settings Adjust Pacemaker Settings Adjustment of Infusions Allergen Immunotherapy Ambulatory Halux 02 Saturation Anesthesia - Nitrous Oxide Analgesia Anesthesia Local Anesthesia Regional Anoscopy Arterial Blood Gas Arterial Blood Gas Puncture Arterial line placement Arterial Line Removal Arterial Sheath Removal - >4 in. Arthrocentesis Audiometry AV Fistula Sheath Removal Bone Marrow Aspiration Breath Hydrogen Test Camino Bolt Removal Central Line Placement & Mgt. Central Venous Line Placement Central Venous Line Rewire Cerumen Impaction Removal Chemotherapy - PO/IVlIntrathecal Chest Tubes - Clamp and/or Remove Chest Tubes - Insertion & Mgt Conscious Sedation CPR Ear Wicks - Insert & Remove EMG EMG Biofeedback Endotracheal Intubation Epicardial Pacing Wire Removal Extubation Foreign Body Removal - External auditory Foreign Body Removal - Nasal Foreign Body Removal - Subcutaneous Foreign Body Removal - Subungual Neonatal Ped Adol Adult Geriatric ILV c. too r Page 1 of 4

35 -r>, _~ 'rocedure Foreign Body Removal - Vagina FracturelDislocations (Closed) Anterior Shoulder FracturelDislocations (Closed) App Immobiliz Dev FracturelDislocations (Closed) Digital Dislocation FracturelDislocations (Closed) Patellar Hansel Histamine Smear - Nasal Secretions IncisionlDrainage Initiation Provocation of Infusions of Abscesses Insert Transvenous Pacemaker Intermittent Catheterization Tx Intracardiac Catheter Removal Intradermal Skin Testing Intubation & Mechanical Ventilation IV Medications & Fluids - Administration Jackson Pratt Drain Removal Lab Test - Blood Cultures Lab Test - Cervical Lab Test - Dipstick Lab Test - Rectal Cultures Urinalysis Cultures - Draw Lab Test - Soft Tissue Site Cultures Lab Test - Throat Lab Test - Urethral Lab Test - Vaginal Lumbar Puncture Mediastinal Cultures Cultures Cultures Chest Tube Removal Microscope Eval - Breast Discharge Microscope Eval - Post Coital Cervical Mucous Microscope Eval- Urine Microscope Eval- Vaginal Secretions Nail TrephinationlRemoval Needle Biopsy of Liver Omaya Reservoir PAP Smear Paracentesis Percutaneous Skin Testing Peripheral Central Venous Line Placement Pulmonary Artery Catheter Placement Pulmonary Artery Catheter Removal,,_, Pulmonary Function Tests Remove Transvenous Sigmoidoscopy Slit Lamp Exam Spirometry Surgical Assist Surgical Drain Removal Thoracentesis Tonometry TPN Ordering Tracheostomy Transtracheal Typanometry Pacemaker Tubes - Remove Aspiration Urodynamic Studies * Percutaneous EMG Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Simple Office Cystometrics Urodynamic Studies - Urodynamic Catheterization Venous Sheath Removal Ventriculostomy Catheter Removal Neonatal Ped Adol Adult Geriatric ( c. c c C. G Page 2 of 4

36 '<, -r-r-, ---- zledical Wound Mgt - Debridement Wound Mgt - Assess for Functional Integrity Wound Wound Wound Wound Mgt - Closure Mgt - Dressing Mgt - Electrocoagulation Mgt - Immobilization Wound Mgt - Removal of Sutures/Staples Wound Mgt - Wound preparation Allergyllmmun DifDx & Tx Arterial Cardiac Blood Gas Interpretation Rehab Cardiovascular DifDx & Tx Cholecystitis Cirrhosis CNS Infections Contraceptive CVARehab Counseling Dermatologic Diseases - Dx & Tx Dermatomyositis Diabetes Mellitus Drug Reaction & Overdose Electrolyte & Water Balance EndocrinelMetabolic DifDx & Tx Geriatric Gouty Arthritis Med Dif Dx & Tx Dif Dx & Tx Gynecologic Routine Dif Dx & Tx Health Maintenance & Disease Prevention Heme/Onc Dif Dx & Tx Hepatic Diseases DifDx & Tx HIV,AIDS ICP Adjust Treatment Protocols Immunization Impotence - Evaluation & Mgt Infectious Disease Dif Dx & Tx Infertility Initial Eval & Mgt Management of an emergency/precipitous delivery Neurodegenerative Neurological Disorders Dif Dx & Tx Nutritional Status - Eval & Mgt Osteoarthritis Pain Management Pancreatitis Pituitary Conditions Psychophysiologic Pulmonary Renal DifDx Renal failure Dif Dx & Tx & Tx Rheumatic Fever - Acute Rheumatoid Arthritis Dif Dx & Tx RheumatologicNasc DifDx & Tx Serum Sickness Spinal Shock - Mgt Thrombophlebitis Urologic Urticaria Disease - Dif Dx & Tx Ventilator Weaning Mgt Admissions (with MD collaboration) Neonatal Ped Adol Adult Geriatric c. C c c. C- G r C C- c: C-- C L- C. C. C C- C C- G l C- C c. C c. c..:.- c. G- C- C C c. L C L c. C. c. c.. G G C C C. C C C. C C- C- G r (' c. C- C C c- C- C. C. C, G c C- C C c. L.- C C. C c. c. c.., r: C C Page 3 of 4

37 OTHER Dx, Assessment &. Mgt Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Evaluate - Radiographs Evaluate - Urodynamic Studies Evaluate Exercise Stress Test Evaluate Ultrasound Studies History and Physical Hospital Rounds Order - ECG Order - Echocardiogram Order - EEG Order - Holter Monitoring Order - Labs Order - Radiographs Order - Urodynamic Studies Order Consults Order Exercise Stress Test Order Medications Order Ultrasound Studies Patient Education Telephone Triage/Consultation PRIVILEGES Neonatal Ped Adol Adult Geriatric c. c. c. c. c. C- c. c c C- C C c C- C C- C. C- <: c. c. c C- C c. <..: (- c r. G C- c. C- C. C- C. c. ('~ C- l. C- c... C \... c. C c: 1-' 11-D1 DATE Na e Printed As the Collaborating Physician and Department ChairlServ e Cen r Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance an lity indicators (if renewing privileges) as related to requested privileges and agree that the above named practitioners qualifications are appropriate. /}' /2.->_ -- '. li". S'/.w?'...(OA... ~n Signature Name Printed DATE Alternate Sup g Physician Signature Name Printed 5~v t,- ~ DATE Alternate Supervising Physician Signature Name Printed Page 4 of 4

38 AHP Clinical Privileges Update Form Department of Pediatrics! NNP Lbave 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): Current Privileges not to be renewed: * *Pfivileges 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. Date \d~~ Practitioner's Signatur~ As the Supervising Physician/QI Liaison/Department Chairl Directorl Service Center Administrator, we have reviewed the above-named AHP's level of experience, past performance a~d quality indicators (if renewing privileges) as r-fed to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ~.iintment, we have reviewed applicable information from the following sources of quality and utilization data: Record Review AJjrtual. Evaluation Ei Continuing Education Conferences D SfudentEvaluation IIi Physical & Mental Health related to Job Performance D Annual Review by Dept. Chair or SCA g Risk Management Events/Quality Management Reports for claims a Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other_ ~ _ We find as follows: J"Acceptable review with recommendation of reappointment with clinical privileges as requested., [J Concerns noted on review with corrective action plan in place with recommendation of reappointment with privileges Robert Boyle, M.D. Printed Name Joshua Attridge, M.D. Printed Ni:ulle Santina Zanelli,M.D.- Printed Name David Kaufman, Printed Name M.D. Date Terry Lucas, RN, MSN Printed Name Date Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005

39 Privilege List for: Neonatal Nurse Practitioner '- lo-apr-08 Name: Date: PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRNILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A The applicant will not undertake patient management except in emergency, B The applicant will manage patients with physician present. C The applicant will manage patients in collaboration and/or consultation with the physician. ;.!rocedure..., \1edical Arterial cannulation Chest Tubes - Clamp and/or Remove Chest Tubes - Insertion Circumcision CPR ECMO & Mgt Exchange Transfusion Intubation & Mechanical Ventilation Lumbar Puncture Mickey Gastrostomy Buttons - Changing Neonatal Resuscitation Pacemaker Insertion - Assist PEG Placement - Assist Peripheral Central Venous Line Placement Peritoneal dialysis PH Probe - Insertion & Verification of Placement Sedation TPN Ordering Umbilical Catheter - Arterial or Venous Birth Defects Eval Cardiac Care - Pre & Post Op Cardiovascular Dif Dx & Tx Congenital Heart Disease Hyperbilirubinemia Immunization Intubation & Mechanical Ventilation Neonatal Intensive DifDx & Tx Neonate Sepsis Newborn screening NICU - PreiPost NICU - Sedation Op Mgt & Pain Control Nutritional Status - Eval & Mgt Premature Disorders Dx & Tx Premie Growth & Development Prenatal Counseling Ventilator Weaning Mgt Admissions (with MD collaboration) Dx, Assessment & Mgt Evaluate - ECG Evaluate - Echocardiogram Evaluate - EEG Neonatal Ped Adol Adult Geriatric C- I e, L- Co. Co. C!.. c:- C C

40 Evaluate - Labs Evaluate - Radiographs -:eneral History and Physical Jeneral Hospital Rounds Order - ECG Order - Echocardiogram Order - EEG Order - Labs Order - Radiographs Order Consults Order Medications Patient Education Telephone Triage/Consultation OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric c; e, e, e, e, e, e, DATE Name Printed - " As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the abovenamed practitioner's level of experience, past performance and quality indicators (if renewing privileges) as 1 related to requested privileges and agree that the above named practitioners qualifications are appropriate. f C-" 'ATE 5{ foy s/)/ Ii) ~ DATE r I DATE DATE 5/5/8 skt"k Name Printed Name Printed ~ternate S~pervising Ph sician Signature Name Printed Name Printed DATE 5'fr zl O~ Name Printed

NEONATAL-PERINATAL MEDICINE CLINICAL PRIVILEGES

NEONATAL-PERINATAL MEDICINE CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for