.. Please return completed fonn to Clinical Staff Office, Box Request for Laser Privileges. Department of Urology Division of :
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1 OVA Medical Center,.UVA Transitiol18rCareH08pital & UVA Health South Rehabilitation Hospital Request for Laser Privileges Department of Urology Division of : Physician Name: Mark Passare~ M.D. Please check those types oflasers that you are requesting privileges for~ and indicate type oftraining/experience. TYPE OF EXPERIENCE: I 2 3 Completed F()l"Ill81 Training LimitedExperience - without formal training Extensive Experience - without fonnal training rience Date Cliriician~s Signature As Division HeadlQI Liaison and Depa.rttnent Chair, we have reviewed the above named clinician~s level ofexperience and past performance as related to requested privileges and agree that the clinician's qualificatio:q,s,are appropriate. Date.. Please return completed fonn to Clinical Staff Office, Box Rev
2 Clinical Privileges Update Form Mark Passarella Department of Urology IVERSI'lY q RGINIA lieai.xhsystem 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 as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. Ifprivileges 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 CLINICIAN SIGNATURE As the Division Head/QI Liaison and Department ChairlMedical 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. Sinc\fhe date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We find as follows: E k.acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D 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 follows: DATE DATE DEPARTMENT CHAIR SIGNATURE Revised 3/1/l006
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11 Clinical Privileges Update Form Mark Passarella Department ofurology 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:* f*pri~leges not renewed are not reported as being voluntarily relinquished unless this done while you are under investigation; lor, 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. - C~SlltJP 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 the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data:. We find ~s 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 follows: DATE DATE 3 Revised 3/112006
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~ ~..._..._...~..._ CLINICIAN SIGNATURE
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