.\ '1i. [21' Acceptable review with recommendation of reappointment to the clinical staff with clini~ar.prjvileges as requested. "-.

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Karin Horton
5 years ago
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1 Clinical Privileges Update Form -"-~-""'-~-""'--l UNlVERSTIY q; VIRGINIA James Bergin Department of Medicine HEALTH SYsTEM I bave reviewed tbe privileges previously granted to me and request tbe following cbanges 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:* ~... --~ ~---~-~-~~-~ ~ l*~p;i;;il;ges~'not renewed are not reported as" bei';g' voi~"~xt;'~ily relin(i~ished unless is done you are under invhtig;i&;;;"'~' 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..\ '1i. DATE As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level ofexperience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Sincefhe date of the last appointment, we have reviewed applicable information from the followin~ sources of quality and utilization data:., r " We r~""'ollows: 1 [21' Acceptable review with recommendation of reappointment to the clinical staff with clini~ar.prjvileges 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. --_..._--_._-- DATE DEPARTMENT CHAIR SIGNATURE Revlo<d 3/1/2006

29 Clinical Privileges Update Form James Bergin Department of Medicine 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 ofexperience): ---~ ~-~--~ -.-~~ ~~. Current Privileges not to be Renewed:'" ---_._ _---_..._--- j*privileges not renewed are not reported as voluntarily relinquished unless done while you are undlee;r:i;;~;e;tiigatio~; lor, in return for not conducting an investigation or proeeeding. If privileges are to be reported as voluntarily relinquished you iwill be notified and reeeive a copy of the report to be filed with the National Practitioner Databank. '2-( (3/" DATE ~. CL~CIAN~ATURE 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 qualifications are appropriate. Sinceihe 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 ~_~)31" DATE DATE 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: Lawrence Girnple, MD.~'-' J~~"L#~-=::::==:::::::: c-- Division Chief/Quality Liaison Mitchell Rosner, MD Interim Department Chair Revised lfl/loo6

~ ~..._..._...~..._ CLINICIAN SIGNATURE

~ ~..._..._...~..._ 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