AHP Clinical Privileges Update Form Steven Rabinowitz, CRNA Department of Anesthesiology ve reviewed the privileges previously granted (copy attached) to me and request the following changes: l"t::w 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 thfs is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported s oluntarily relinquished you will be notified and receive a copy of the report to be flied with the National Practitioner D bank. Date, As the Supervising Physician/QI Liaison/Department Chair/Medtcal 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 llm\ointment, we have reviewed applicable information from the following sources of quality and utilization data: \t Medical Record Review ~ Continuing Education Conferences ~ Physical & Mental Health related to Job Performance,j{l Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SeA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other --------------------------------------------------------------------~---------------- We find as follows: if'acceptablereview 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 _ I. as requested, but ~a revi:w in ~ths.< z., 15J'l.tXQ Dc~O-,-,<_a"r:*s-<.~~.tIJ Barbara Castro; M.D. Date Primary Supe. I h sician Sign ure Printed Name -V(('~ Date George Rich, M.D. Printed Name Date Alternate Supervising PhYSicianSignature Printed Name <--, Date < d'1j-~110 Date ' Printed Name Donna Via, Administrator Printed Name Date Chair/RPC Medical Director Signature (for HSFemployees) Printed Name revised 3/1/2005

Privilege List for: Certified Registered Nurse Anesthetist l~ame: $TEl""G?v' 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 PRACTICE SHOULD BE LEFT BLANK. ACCORDING TO THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE 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. ~--'<\cedure.cedure Medical Medical Medical Medical Medical Airway Mgt - Bronchoscopy & Intubation, Fiber Opt Airway Mgt - Combi-tubes Airway Mgt - Laryngeal Mask Airways Airway Mgt - Mask Ventilation Airway Mgt - Percutaneous Tracheostomy Anesthesia - Caudal Blocks Anesthesia - Digital Blocks Anesthesia - Epidural Blocks & Catheter Place. Anesthesia - General, Inhalation Anesthesia - IV Blocks Anesthesia - Peripheral Nerve Blocks Anesthesia - Subarachnoid Blocks & Catheter Place. Anesthesia - Subcutaneous Anesthesia - Topicalization of Airway Anesthesia - Transtracheal Blocks Anesthesia Local Anesthesia Regional Arterial line placement Blood Product Administration Cath Swan Ganz catheter placement Catheter - IV Peripheral - Placement & Mgt Catheters - Central Venous Pressure Endotracheal Intubation Injections - Intravenous, Gen'l Anesthesia Med Administration - Epidural Med Administration - Intrathecal Med Administration - Oral Med Administration - Topical Anesthesia Care Plan Post Anesthesia Evaluation Post Anesthesia Mgt Preanesthetic Consent Preanesthetic Evaluation Neonatal Ped Adol Adult Geriatric -e. c::... C < <, <. c <. e; A,).c' A A- c, <: < <:::.. c. c; c, ic-1 ----+--<.-=----1, 1----+--"'C'"--+----<---..:...4 <... "". -J, c <.. e; - I <::::..- C- c:::::..c... i L- ~.-===~ ~. ~ ~

OTHER PRIVILEGES Neonatal Ped Adol,Adult Geriatric ---------------------------------------------------------------------- DATE ~~~ Signature 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. ~---'--I~ f 13 ) O~ DATE _----'1 L/~ J DATE os ~.. ~-=--~--+--,\-cj..~ &.6.<... c: Primary Super sing Physician Signature Name Printed ----------------------------------------------------- DATE Alternate Supervising Physician Signature Name Printed DATE ~TE ---/--~ =_r_-------'~~~~ulcb t1)d Name rinted 1