Clinical PrivilKes Update Form Christine Lau Department ofsurgery I have reviewed the privileges previously granted to me and request the following ch

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10 Clinical PrivilKes Update Form Christine Lau Department ofsurgery I have reviewed the privileges previously granted to me and request the following changes to include any new therapieb, 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:._ _._._.._.... r;.p~l~i~i;;~~t ~e~ewed;rn;.."i.;p~;t;d ;U. ~voiu.ta~lly r~ti~q~iibl;d-~nless~tbis'b-d;,;---i;;~"u;;~ ;;id;.t~;.;dg;tton; lor, in return for not eondueting an Investigation or proceeding. Ifprivileges are to be repo d voluntarily relinquished you jwld be notified and receive a eopy of tbe report to be filed wltla tlall National Praedtloner ata ok. ".--'--H~- DATE As the Division Head/QI Uaison and Department ChairlMedi I Director, we have reviewed the abovenamed clinician's level ofexperience, past performance and quanty indicators (ifrenewingprivueges) as related to requested privileges and agree that the above named cjhdeian's qualifications are appropriate. Since tbe date of the last appointment, we have reviewed applieable information from the following sources of quauf and uttuzatiod data:. We find as follows: [X] 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 montha. [J Should... cllnlc.1 prm_ granted but...tric\ed.s foil_~ -D-A-TE--L1_1_~Vj Ly ~~NSl"""~ -J-#---T-'tq-J(. ~....,_n_n G4..._n_... DATE DEPARTMENT CHAIR SIGNATURE

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12 ~ ~- Clinical Privileges Update Form UJ'JIVERSITY Q!VrRGINIA Christine Lau Department of Surgery HEALTH SYsTEM 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: * ---_.._--_... _-- r;p~i;ileges n~t;;;e;:edare not reported;~ being voluntarily relinqulshed'~~iess'thi!li;done whiiey~~' a;e;~d;ri;~estigati;;;~" lor, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquisbed you Iwill be notified and receive a copy of tbe report to be filed witb the National Practition atabank. CLINICIAN 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. Since the date ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We find as follows: :tj Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested _ 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: /6 F(;~ If ~~ DIVISION HEAD/QI LIAISON SIGNATURE m~/iqiij _ '---~- DEPARTMENT CHAIR SIGNATURE Revised 1I11l006

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

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