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57 AHPClinical Privileges Update Form _Carol Ballew Department of Cardiology Clinic 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 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. -~)r&~~- --- Practitioner's Sig~e As the Supervising Physician/QI LiaisonlDepartmentChairl Director/ Service Center Administrator, we have reviewed the above-named AIJP'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 -s.appctntment, we have reviewed applicable information from the following sources of quality and utilization data: [i RecordReview ' Continuing Education Conferences 51 Physical & Mental.Health related to Job Performance &' Risk Management Events/Quality Management Reports for claims g Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA [jj'prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other~. ~ ~ ~ _ We find as follows: if Acceptable review with recommendation of reappointment with clinical privileges as requested. D Concerns noted on review with corrective action plan in placewith recommendation of reappointment with privileges as requested, but subjecttoa review in months. Date. ~. Primary ~rvising Physician Signature James Bergin. M.D. Printed Name ~-..- Altorn~t~ #rvisinaphysician Signature,f.,Alternate,...,i Su A1lail SirilPSOl1, M.B. Printed Name S~M~ Ka.~ M.O. PrintedJi me. Date 1\'10 0'1 Date Printed Name Karen Forsman, Administrator Printed Name /', Date I ChairlRPC Medica,l Director Signature (for HSF employees) Printed Name revised 3/1/2005

58 AHP Clinical Privileges Update Form. &Ql ~ Department of Card [0 l?:t Nt nil- I have reviewed the privileges previously granted (copy attached) to me and request e 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 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 Practitioner's Signature As the Supervising PhysicianJQI 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,~related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of the last ippointment, we have reviewed applicable information from the following sources of quality and utilization data: Gr Record Review [!3'"Continuing Education Conferences QI Physical & Mental Health related to Job Performance 0- Risk Management Events/Quality Management Reports for claims [ill Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ['ij'" Annual Evaluation o Student Evaluation o 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. 17-/1'1 {U'"1 5j~~ Date /t:?/~/b1) 7 D~ 5~~) &~ ~p~r7im--a-r~~~~e~~~s~in-g-p~h-ys~i~c~ia-n-=s~ig-n-a~t-u-re Printed Name ~ "\ Alternate Supervising Physician I ature Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature i'). I"J. 0<\-- Date ~'- ~V7Y'r'V Clinical are Svcs Administrator (for Me employees) Printed Name ~J-,VO(IJrno/' Printed Name Date Chair/RPC Director Signature (for HSFemployees) Printed Name

59 AHP Clinical Privileges Update Form L2a.n>, MeuJ Department of C!.a.rc1{o { 0S# CJ{h ( C Ihave 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. 1\~fS: -0('" CQ)JJ-w(b e~t,.!y Date Practitioner's Signature As the Supervising Physician/QI Liaison/Department ChairI 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: r ~ [M" Record Review f0' Continuing Education Conferences c:,v/physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims 13' Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Oilier 5r o Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA _ 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.,-z ---- { (,?" I I vt -=-:-..:l_' -~-=-----,tnf7. -T"--=----:--:---::-: Date Primary Supe~g PhYSICIan SIgnature /1/-vJ/O;) f~/ll~ / Dato/ Alteln~ing Physician Signature Printed Name U Printed Name. Date Alternate Supervising Physician Signature Printed Name I Date Clinical Care Svcs Administrator (for Me employees) Printed Name -r<1_ RV:lMqi'] Printed Name Date Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005

60 \) V,,) \;I\[JU[JI~ I ) VI' \; r' UVJ AHP Clinical Privileges Upd ate Form - &0/ L']c;j(e0 Department or CatdrC>!Df;i Cirf1{C. I have reviewed the privileges previously granted (copy all ached) to me d request the following chunges: New Privileces to De Added (please Indicate category level and type of experience): Revised.1/27/21103 Current Privile~cs not to be renewcg: Y< "Prl,'llegel: not renewed are not reported IIW being Yoluntarily rulinqulslred unless tilts is done while yon arc under lnvestigation; or, In return for not tonduttlng an lnvcstlgution or prneccrllng. If privileges un: to be reported as voluntarily r ellnqulshcd you "1'111be n otifled And rccelvo a copy of the report to be Illed with the ],\(utlonmipractitlcner Datubnnk, Dute /(-ld18 Practitioner's Sigmnure As the Supervising Physlcian/Q! Liuison/Department ChllirfMedlcaJ Director/ Service Center Administrator, W(! have -~viewed the above-named AHP'9 level of experience. past performance and quality indicators (if renewing privileges) as ated 1'0 requested privileges and agree that the above named AHP's qualifications arc apprcpria te. Since the dille uf the last appointment, we have reviewed applicable Information from the following snurces of qualtty and urilization data: Record Review t3 Annual Evaluation o Student Evuluation! ~..Continuing Education Conferences Physical & Mental Health related to Job Performance o Annual Review by Dept. Chuir or SeA Risk Management Events/Quality Management Rt!POTl8 for claims Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other. _ We find as follows: J5t Acceptable review with reccrnrnandatlon of reappointment with clinical privileges as requastad. o Concern II notad on review with corrective action plan In place with recommendation of reappointment with prlvllaqee as raquastad, but subject to a review In months. II ( 1-1 ( a J Date Alternata Supervllling Ph lclan Signaturo t Printed Name Date i.:}...\ \ 11I;l DO:::' Date Altarante Supervl&lna Physician Signature Printed Name ~U1w.~'--' Service Cntr Administrator (for Canter employees) printed Nama Date Cr.alr/Madlcal Dlrector Signature (for HSF employees I Prtnre d Nama

61 Revised 5/27/ nave reviewed the privileges previously granted (copy attached) to me d 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 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. }(-;to 13 Date Practitioner's Signature As the Supervising PhysicianlQI Liaison/Department 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 -----,iointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA Record Review ~ Continuing Education Conferences y:x Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims 1i1 Prescriptive Other Privileges (8 hours continuing eduacation documentation required every 2 years) _ 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 reappolntment with privileges as requested, but subject to a review in months. II l"ll {(jj Date 11/"1-t/() 3 Date Printed Name,4. ~(t-j- UL~1 ~P'-:ri.:...nt-e...,d...,N-:-a...;.m-e--+---,11/ or Date Alternate Supervising Physician Signature Printed Name Date Alterante Supervising Physician Signature Printed Name 12-:\ \ 1/1;200~ Date IU ~ ~'-----' r;.~.for::>ryi ti. (1 Service Cntr Administrator (for Center employees) Printed Name Date Chair/ Director Signature (for HSFemployees) Printed Name

62 Privilege List for Acute Care Nurse Practitioner 19-Dec-02 Name:.. a.tdq.., Cr- '0..Al\\tv...L) _ Date: 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 WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACfICE SHOULD BE LEFf BLANK. ACCORDING TO CATEGORY, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVTLEGE: 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. ~-----\1edical General General General,-,General 1edical Immunization Cardiac Rehab AllergylImmun Cardiovascular EndocrinelMetabolic Renal Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Die Dx & Tx. Rheumatologic!Vasc DifDx & Tx Geriatric Cholecystitis Pancreatitis Cirrhosis Dif Dx & Tx Infertility Initial Eval & Mgt Diabetes Renal Mellitus failure Derrnatologic Diseases- Dx & Tx Anesthesia Tonometry Percutaneous Local Incision/Drainage Anoscopy Sigmoidoscopy Arterial mood Gas Bone Marrow Paracentesis Skin Testing of Abscesses Aspiration Lumbar Puncture Foreign Body Removal> Subcutaneous Foreign Body Removal> Subungual Foreign Body Removal External auditory Wound Mgt. Assess for Functional Integrity Wound Mgt Wound preparation Allergen Immunotherapy Pain Management History Telephone Hospital Order and Physical Triage/Consultation Rounds Medications CNS Infections Health Maintenance & Disease Prevention Chest Tubes Clamp and/or Remove Neonatal Ped Adol Adult Geriatric v V c, C- 6 {' (l (l r./ (1 {'/ (,--, ('-1 ~ C e- 6 ('j r~ 0, V G c. C,; (\/ c- 0 c.." c, c. ('J (0 U Page 1 of 4

63 ,---'" General General General General General General ~eneral General General General General General General General._, rocedure Intradermal Lab Test - Vaginal Lab Test - Throat Skin Testing Cultures Cultures Lab Test - Soft Tissue Site Cultures Lab Test - Blood Cultures Surgical Assist Tracheostomy Transtracheal - Draw Tubes - Remove Aspiration Microscope Eval - Breast Discharge Intermittent Catheterization Tx Urodynamic Studies - Simple Office Cystornetrics Urodynamic Studies - Rectal Tube Insertion Urodynarnlc Studies - Percutaneous EMG ICP Adjust Treatment Protocols Thrombophlebitis Ambulatory Halux 02 Saturation Hansel Smear - Nasal Secretions Intracardiac Catheter Removal Omaya Reservoir Typanornetry Epicardial Pacing Wire Removal Pulmonary Artery Catheter removal Derma tomyosi tis Order-ECG Order - Holter Monitoring Order - Labs Order - Radiographs Order - Urodynamic Studies Authorized Evaluate to Prescribe - ECG Evaluate - EEG Evaluate - Holter Monitoring Evaluate - Labs Central Line Placement & Mgt, Order Exercise Stress Test Evaluate Exercise Stress Test Order Ultrasound Studies Evaluate Ultrasound Studies Adjust Intra-Aortic Balloon Pump Settings Insert Transvenous Pacemaker Remove Transvenous Pacemaker Chest Tubes - Insertion & Mgt Mediastinal Chest Tube Removal Jackson Pratt Drain Removal Pulmonary Artery Catheter Placement Central Central Arterial Arterial Arterial Arterial Venous Line Placement Venous Line Rewire line placement Line Removal Blood Gas Puncture Blood Gas Interpretation Arterial Sheath Removal - >4 in. Venous Sheath Removal AV Fistula Sheath Removal Needle Biopsy of Liver Intubation & Mechanical Ventilation Extubation Neonatal < Ped Adol Adult Geriatric t/ 0 (~ c. (h (I o r (" c. o (\./ r- t c r~ ('/ ('~ (\ (I {'/ n r: r (- r- Page 2 of 4

64 _~-?rocedure General General ~eneral General General General /-~rocedure.edical IV Medications Initiation Adjustment TPN Ordering of Infusions & Fluids - Administration of Infusions Ventriculostomy Catheter Removal Foreign Body Removal - Vagina Adjust Pacemaker Settings Wound Camino Mgt - Debridement Bolt Removal Adjust Cardiac Assist Devices Urticaria Wound Spinal Wound EMG Mgt - Dressing Shock - Mgt Mgt - Closure Biofeedback Arthrocentesis Gynecologic Routine Dif Dx & Tx Thoracentesis CPR Endotracheal Wound Intubation Mgt - Immobilization Breath Hydrogen Test Serum Sickness Foreign Body Removal - Nasal Order- EEG Order - Echocardiogram Hepatic Diseases Dif Dx & Tx Lab Test - Cervical Order Infectious Consults Lab Test - Rectal Lab Test - Urethral Cultures Disease Dif Dx & Tx Cultures Cultures Nutritional Status- Eval & Mgt Osteoarthritis Lab Tesr- Dipstick Urinalysis Contraceptive Counseling Peripheral Central Venous Line Placement Chemotherapy - PO!IVlIntrathecal Cerumen Impaction Removal Ventilator Weaning Mgt Gouty Arthritis Urodynamic Studies - Urodynamic Catheterization Histamine Provocation Wound Mgt Removal of Sutures/Staples Urologic Disease - Dif Dx & Tx Impotence - Evaluation & Mgt Surgical Drain Removal- Dx, Assessment & Mgt Microscope Eval Post Coital Cervical Mucous Microscope Eval- Vaginal Secretions Microscope Patient Admissions Wound Mgt > Heme/One Audiometry Slit Lamp Education Eval Urine (with MD collaboration) Electrocoagulation Dif Dx & Tx Exam Neonatal Ped Adol Adult Geriatric ('l./ C/ G c. C'.., (\1 (I... () r/ (1./ (' r" (i (1 - '-" C" r- ~ (0./ (" {'/ 0f 0... {' (II (. ('/ (\J (l (l r-j '-' (\ r Page 3 of 4

65 CV A Rehab Pulmonary Dif Dx & Tx, Spirometry Neurological Dif Dx & Tx General Med Dif Dx & Tx EMG General Evaluate - Echocardlogram Neurodegenerative Disorders Anesthesia Regional Pulmonary Function Testss Psychophysiologic Dif Dx & Tx Electrolyte & Water Balance Rheumatoid Arthritis General Evaluate - Radiographs Pituitary Conditions PAP Smear HIV, AIDS Rheumatic Fever - Acute General Evaluate - Urodynamic Studies Drug Reaction & Overdose OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric (/ 0 (\/ c, ~/ ("' (J (\ ('\/ [1) 0/ f\ ('I i' ~ (" u DATE ~fv\.- J I ~D()3 Signature Cara(e "tallew 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 related to requested privileges and agree that the above named practitioners qualifications are appropriate. r- DATE Principal Supe,. ng Physician Signature Name Printed DATE DAT Alternate Supervising Physician Signature Name Printed DAT Dept Chair or Svc Center Administrator Name Printed Page 4 of 4

PEDIATRIC EMERGENCY MEDICINE CLINICAL PRIVILEGES

PEDIATRIC EMERGENCY MEDICINE CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 1/6/2016 Applicant: Check off the Requested box for each