~'?fvirginia U IVERSITY --.. "J. Clinical Privileges Update Form ~ _--..._---...

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1 U IVERSITY --.. "J ~'?fvirginia Chrlstopber Moskaluk epartment ofpathology..dull HF.ALTH ~'ystem I have reviewed the privileges previously granted to me and request tbe following changes to Include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentatiqn to verify competency): New PriviJeges to be Added (please indicate category level and type of experience): ~ ~ _..._------"----._ _...._-_....._--...._--.-_.._-_..._-_ Current Privileges not to be Renewed:" ---._ _ _.._... _-_.. _-..._-_.. "--'._----_.._--_._.._. -_..._... _-.._-_.._._-._--.._--.._ I.P~lvlleges not renewed,,~e not reported as being;~lunia~iiy reiiqui;l;edu~l~thlsbid~;ie' whliey;;q"rreu~del' Invesiig.ti~II;. ior, III return for not conducting an investigation or proceeding. If privileges are to be reported 115 voluntarily relinquished you will be notified and receive a copy of the report to be filed with the Nationlll Practitioner atabank. As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed related to requested privileges and agree that tbe above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following SOlJrees of qualty and utilization data: We find as)'dliows:' / ' '\ i_i\a""a_. Acccc'eptable review with recommendation of reappointment to the clinical staff with clinical ~rlyllegas as requested.,.~ < Concerns noted on review with corrective action plan in place with recommendation of reappqlntment to the clinical staff with privileges as requested, but subject to a review In months. Should have clinical privileges granted but restricted as follows:. ---i--"ri''---'"--i ~-..--ol "--

2 Christopher Moskaluk epartment of Pathology 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): 1\. / l V cj (V1.u-r,'fS Current Privileges not to be Renewed: * j*privileges not renewed are not report~d as being voluntarily relinqui~hed 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 relinquisbed you 'will be notified and receive a copy of tbe report to be filed with the National Practitioner atabank. _~3:/!~/(L~ As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ws: cceptable 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: 1.., " 11.0.\\ ~ -pit II( EPARTMENTCHAl~ Revised

3 Christopher I Moskaluk epartment of Pathology U~IVERSITY o/virginia.,iiealthsysrem 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): Current Privileges not to he 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 vhe report to be filed with the National Practitioner atabank. CLINICIAN SIGNAfURE As the ivision Head/QI Llalson and epartment ChairlMedical irector, we have reviewed the abovenamed Since the date of the last appointment, we have reviewed applicable information from the following sources of, quality and utilization data: We find as follows: ~cceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested ' Concerns noted on re\liew 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: _ ::~----- Revised

4 Clinical Privil(~gesUpdate Form --Christopher Moskaluk epartment of Pathology U~RSIT'Y ~'?_ VIRGINIA!Ill! I-fEALTH SYSTF..lVl 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): 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; -r'> 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 atabank. CLINICIAN SI ATURE As the ivision Head/QI Liaison and epartment ChairlMedical irector, we have reviewed the abovenamed Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We find as follows: VJ 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: _ EP~~ Revised 3/]/2006

5 Christopher Moskaluk epartment of Pathology _---.I have reviewed the privileges previously granted to me and request the following changes: Current Privileges not to be Renewed:* [;;'P;i~ ii;'g;~-~-;;t ;~-';;~;~ d ;;~~ ~~i-;:;p~';tt;d";;b; i"~g-~~i~~ta'~iiy"~-;ii;;-q~ish~'d"~'~i;~;t'h'i;i;-d~;;';h"ii;y;;;;re u;;-der invwig;tio n;-' [nr, in return for not conducting an investigation or proceeding, If privileges are to be reported as voluntarily relinquished you iwill be notified and receive a copy of the report to be filed with the National Practitioner atabank. As the ivision Head/QI Liaison and epartment ChairlMedical irector, we have reviewed the abovenamed Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: 10 Number: 1:;)(' S,s'f Sentinel Events/Risk Management Reports Physician's Health & Mental Status We f~ollows: L::'J 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: _ IVISION HEA/QI LIAISON SIGNATURE t~1(05 EPARTMENT CH IGN URE ~~ Revbedl0l17!OI

6 Christopher Moskaluk epartment of Pathology I have reviewed the privileges previously granted to me and request the following changes: New Privilegc!s to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* r;;p~~gcs";;~~-;;;wed';-~-;;~t7eported-;;;-bei~g vo'i~~t;riiy relinquished u~ie-;;ws i;d~-';-~-;hile you are under investig;'tlo-;;;' ~or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you jwiii be notified and receive a copy of the report to be filed with the National Practitioner atabank. t{ lib/a 3 CLINICIAN S GNA TURE As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~'~ , I Number: 1~~5!!>'-f' Physician's Health & Mental Status Sentinel Events/Risk Management Reports We find as follows: 8'Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested o Should 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. have clinical privileges granted but restricted as follows: _ L!pjo3 IVISION HEA/QI LIAISON SIGNATURE E~~H SIGNATURE R~visedlO/17/01

7 Clinical Privileges Update Form, Christopher Moskaluk epartment of Pathology I have reviewed the privileges previously granted to me and request the following changes: Current Privileges not to be Renewed: * I*Privileges not renewed~re not;.eported as being v~tuntarily rel'inquish~dunless this is done ;:hil;y;;;-;;;; under investigation; lor, in return for not conducting an investigation or proceeding, If privileges are to be reported as voluntarily relinquished you Iwill be notified and receive a copy of the report to be filed with the National Practitioner atabank. CLINICI N SIGNATURE As the ivision Head/QI Liaison and epartment Chair/Medical irector, we have reviewed the abovenamed Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: 110 Number: ~ We find as follows: 1\71' Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as ~ requested o Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but su iect to a review in months. ~A~T=E----~tJ~~_O_\~ ~'/fsfp I 7 I ' _--/-5h~.~~\ ~ E~ENT CHAIR SIGNATURE Revised 12/

REQUEST FOR CLINICAL PRIVILEGES epartment of Pathology University of Virginia Health Sciences Center. Name uke U h 1 vi?v S,,~ ~ 1910 Christopher A. Moskaluk, M.., Ph.

8 REQUEST FOR CLINICAL PRIVILEGES epartment of Pathology University of Virginia Health Sciences Center. Name uke U h 1 vi?v S,,~ ~ 1910 Christopher A. Moskaluk, M.., Ph.. Year of Certification PLEASE MARK AS REQUESTE ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNE TO PRACTICE; EMERGENCY PRIVILEGES SHOUL BE MARKE WHERE YOU ARE THE ESIGNATE PERSON TO COVER AN AREA IN WHICH YOU O NOT REGULARLY PRACTICE. AREAS IN WHICH YOU O NOTREGULARL Y PRACTICE SHOUL BE LEFT BLANK.. According to category, enter A, B or C in the REQUESTE column. Category A ~tegory B The applicant will not perform or direct except in emergency. The applicant will occasionally perform or assist in performance or direction. Consultation will be sought in the event of anticipated or actual difficulties. Category C The applicant will perform independently. The applicant would be expected to request consultation only occasionallv. According to tvpe, enter 7, 2, or 3 in the EXPERIENCE column. Type 1 Completed Formal Training Program Type 2 Limited Experience - without formal training Type 3 Extensive Experience - without formal training BLOO BANK COAGULATION CLINICAL PATHOLOGY CLINICAL CHEMISTRY CYTOPATHOLOGY - IAGNOSIS IAGNOSTIC MOLECULAR PATHOLOGY RUG ABUSE TESTING ~MUNOLOGY I'.dORATORY HEMATOLOGY

_~I MICROBIOLOGY MYCOLOGY PARASITOLOGY POSTMORTEM EXAMINATIONS SEROLOGY SURGICAL PATHOLOGY - GENERAL Specialty Specify TOXICOLOGY VIROLOGY OTHER.. II. PROCEURES.,,:..'.

9 _~I MICROBIOLOGY MYCOLOGY PARASITOLOGY POSTMORTEM EXAMINATIONS SEROLOGY SURGICAL PATHOLOGY - GENERAL Specialty Specify TOXICOLOGY VIROLOGY OTHER.. II. PROCEURES.,,:..'..., According to category, enter A, 8 or C in the REQUESTE column. Category A Category B The applicant will not perform or direct except in emergency. The applicant will occasionally perform or assist in performance or direction. be sought in the event of anticipated or actual difficulties. Consultation will Category C The applicant will perform independently. The applicant would be expected to request consultation only occasionally. According to type, enter 7, 2, or 3 in the EXPERIENCE column. Type 1 Type 2 Completed Formal Training Program Limited Experience - without formal training Type 3 Extensive Experience - without formal training CATEGORY. TYPE PRIVilEGES REQUESTE. REQUESTE EXPERIENCE. (A, B r CJ' (1, 2 r 3) THERAPEUTIC APHERESIS AN STEM CELL COLLECTION CYTOPATHOLOGY - FINE NEELE ASPIRATION OTHER A TE _--,~--,-/2_Y-,-1tt._+ _ CLINICIAN As ivision Head/QI Liaison and epartment Chair, 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 clinician's qualifications are appjopriate. We recommend approval of the requested privileges.. -i» «e:i~ J.t / 2 <{ / q 7 i/~?/ ~ _ ( ---P-hL---:-IV-I--:~~IO~--~-/Q:-I:-L-IA--IS~O~N:----- 'f/ ~ltz. 'tpaatm ~IR din _pri.pth R:11/21/95

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,