r tjnlversrry- Clinical Privileges Update Form 1...qlVIRGINIA Andrew Martof Department of Dentistry II~~!~!.~TH SYSTEM I have reviewed the privileges previously granted to me and reqnest 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:'" --------------------------...'".-~----.. _.,'.'...~~.. _H',_'." '._.~'" ~,". ",.,_.," '.'.",,_ "'~",'.,,",,,..'n "'~"'".',,,,'... ".,. ',..,,,,,,. '..'. _,... '.,,,,.. w..._,..,,',"'<1.,~,...,,'...~-,." _. '.'. "', ". "'"... ", PI'lvlJeges liot renewed lire not reported 88 being voluntarily relinquished IInless tills is done willie you are under Investlgatlou; or. In retllrn for liot conducting an Investigation or proccedlng. If privileges lire to be repoi'ted as voluntarily relillqulshed you will be notilled and receive a copy of the report to be filed with tbe National PI'ac.ftlloncl' Data balik, _6~/[~a~u~!),~.O/34u.// /' TI \ CLINICIAN SIGNATURE Y As the Division HeadlQI 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. Sln.~e the date of tile last appointment, we have reviewed applicable information from the following sources of qullity and utilization data:, We f~ayhllows: ~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. D Should have clinical privileges granted but restricted as follows:.,,=~.. Rovlled 311~
Clinical Privileges Update Form Andrew Martof Department of Dentistry 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): Performance of History and Physical (Documentation of request is available in the Credentials File in the Clinical Staff Office.) Approved by the Credentials Committee: January 13, 2012 Approved by the Clinical Staff Executive Committee: January 17, 2012 Approved by the Medical Center Operating Board: February 23, 2012
Clinical Privileges Update Form Martof Department of Dentistry I [' I U~.<r.rI..r.V....:E..I. l~..sii"y. Cff_.V.. IJR!. G.-IN..IA. '.. HEALTHSYSTEM 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. If privileges are to be reported as voluntarily relinquished you till be notified and receive a copy of the report to be filed with the National Practitioner Databank. 7 -}.2. -/2>._;:>-----_... a~~ij_l ---.-----..- CLINICIAN SIGNATURE As the Division Head/Ql 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 tbe 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 f~~ ~ilows: lj:a" Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested,-. i_j 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. i i Should have clinical privileges granted but restricte L.J --"'d--\=--\.-~-"""~-""'-v----------... Revised 31112006
Clinical Privilf~ges Update Form Martof Department of Dentistry Uft'IVERSITY ~qvirginia!1i111!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 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 Investlgatlon 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. CLINICIAN SI J\TURE As the Division Head/QI Liaison and Department Chair/MedicaI 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 as follows: ~cceptable 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. D Should have clinical privileges granted but r (-- (&- -(f~ ~I_( lo -08 uate DEPARTMENT CHAIR SIGNATURE Revised 3/J12006
Clinical Priyileges Update Form.rdrew Mnrtof Department of Dentistry I have reviewed the privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Prlvileges not to be Renewed:* FPri;ileges-;;-t.:~-~;!;ed-;;~-~~t rep~;ted-;;;b;i;;g-;~'i~-i~t;"~iiy-;:~ii;q ui-;h;d-~-~i;~thi~i;-d~;;~-~hi~-;o~-;;;:;;;~d~';"i;;;;~ti'g;;-ii~';;;- jor, 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. :2. -~ -Ob up!1ltwli -C-L-I-N-IC-I~A-N-S~I~G-N-A-T~U~17r+------------------- 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: ~;~fection Control ~~ and Inpatent Utilization D Medication Utilization ~Medical D Inpatient Costs Record Documentation D Inpatient Activity D Blood Utilization Q/'Patient Satisfaction We find as follows: ~~eptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D 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. Revised J 2128105
-----------_..._-- - Clinical Privileges Update Form Andrew Martof Department of Dentistry I have reviewed the privileges previously granted to me and request the following changes: New Prrvileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* r;'privileges not renewed are not reported as being voluntartly relinquished unless this is done while you are under investigation; ior, 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. ;2.-) -0 if C2---"'----a-----""~'-=------=--~J _ CLINICL~NSIGNATU~ 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 f~ 10 Number: 494138 Infection Reports Patient/Family Satisfaction Sentinel Events/Risk Management Reports Outpatient Clinical Practice Drug Usage Reports Medical Records Reports Physician's ~oliows: Health & Mental Status ~ 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 1ZnJ in months. :11~f~OUld havo clinical.,'vllogo, g,antod b~o~~ ~V~~AD/~G~nURE ~OL{.~~ ~Dd),'>,,----PATE DEPARTMENT CHAIR SIGNATURE RevisedlO/17/01
Clinical Privileges Update Form Andrew Martof Department of Dentistry I have reviewed the privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:*,""r.~ ''''''''.''''... '''''''''''''''. '''''''''''._'_ ''' ''''''''~'',..."', ""',,_,_. '~'"_.~..,.,...~".~ ""'_ """"_,,_... ~~. _r~~-~~ """",_""_""""""""""",.~,,,,, '''''''''''-''''''':''~-"'".-.,<r~.... i*privileges not renewed are not reported as being voluntarily relinquished unless this is 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 iwill be notified and receive a copy of the report to be filed with the National Practitioner Databank. t,_,..,.~...,,~.''''''''''''''~''~'.''''''''.,'~~'_'~'''_''''c><.,",',,". ".,. _.,. " ".'''' ''-"'''''',.~,~ CLINICIAN SIGNATUR$ 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: 10 Number: 494138 Infection Reports PatienUFamily Satisfaction Sentinel Events/Risk Management Reports Outpatient Clinical Practice Drug Usage Reports Medical Records Reports Physician's We find as/follows: Health & Mental Status ~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D 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: _ S-J-o.L- 3/J (0::2-
Clinical Privileges Update Form Andrew Department of Dentistry Martof I have reviewedl the privileges previously granted to me and request the following changes: New Privileges fo be Added (please indicate category level and type of experience):..;0= Current Privileges not to be Renewed: *.er" =Prtvileges 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 ofthe report to be filed with the National Practitioner Databank. 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 of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: Medical Records Reports Drug Usage Reports Outpatient Clinical Practice Infection Reports Sentinel Events/Risk Management Reports Physician's Patient/Family Health & Mental Status Satisfaction We find as follows: ~eptable review with recommendation of reappointment to the clinical staff with clinical privileges as req uested o Concerns noted on review with corrective action plan in p, e with reco mendation of reappointment to the clinical staff with privileges as requested, but sub' ct months. i/-<n(oo -----UAT~ Revised 12128/1999
'~ndrew Martof Department of Dentistry I have reviewed the privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges to be Changed: ~. 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 of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: ~YSiCian's Health and Mental Status o Inpatient Resource Utilization 8'!'nvasive/Non.invasive Procedures ~edical Records Documentation ~ntinel Events/Risk Management Reports ~tpatient Clinical Practice o Peer Review of Clinical Performance ~orbidity _Mortality Reports o Blood Usage Reports o Drug Usage Reports ~fection We find as follows: Control Reports Q-1'atienUFamily Satisfaction ~ceptable 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 subject to a review in months. 03/24/98 Thomas E. Leinbach, D.D.S.
,.' REQUEST FOR CLINICAL PRIVILEGES Department of Dentistry University of Virginia Health Sciences Center Andrew B. Martof, D.D.S. Name 1975 Dental School Year of Graduation North Carolina Memorial Hospital 1975-1977 Residency Training and Years North Carolina Memorial Hospital 1977-1978 Fellows;hipfPost-Residency Training Board Certification in Year of Certification Admitting Privileges? [Xl Yes o No INDICATE THE AREAS IN WHICH YOU REQUEST PRIVILEGES AND NOTE YOUR EXPERIENCE IN THOSE AREAS \"'ategory Category Category Type 1 Type 2 Type 3 A B C According to category, enter A, 8 or C in the REQUESTED column. The applicant will not undertake patient management except in emergency. The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, or 3 in the EXPERIENCE column. Formal Training Program Limited Extensive Experience Experience ACQUIRED DEFORMITIES OF THE ORAL REGION Diagnoses and Treatment C "1 DEVELOPMENTAL ANOMALIES OF THE ORAL Diagnoses and Treatment REGION C 3 DISEASES OF THE DENTAL PULP Diagnoses and Treatment C 3 FACIAL PAIN Diagnoses and Treatment C 3 ~-ECTIOUS DISEASE Diagnoses and Treatment C 3.FECTIOUS DISEASES OF THE TEETH AND Diagnoses and Treatment c PERIODONTAL STRUCTURES 3 TUMORS OF THE JAWS AND PERIODONTAL Diagnoses and Treatment STRUCTURES B 3
Category Category Category Type 1 A B C Accordlnc to cstecorv, enter A, B or C in the REQUESTED column. The applicant will not undertake the procedure except in emergency. The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. Accordino to type, enter 1, 2, or 3 in the EXPERIENCE column. Formal Training Program Type 2 Limited Experience Type 3 Extensive Experience., :u ADJUNCTIVE... ~~.~~~..~':~.~.~~.:":.~~.~~~..~ _ ;.: 9. J. Nitrous oxide analgesia C ':\ DIAGNOSTIC Consultation radiographic... _.c 3. Examination C 3 ENDODONTICS Apicoectomy c 3 ORAL SURGERY ORTHODONTICS Endodontic therapy C 3...~:~:.~.~~~~.~.~ 9. }. Frenectomy - 3...._..._.................... G.............. Implantation C 3... 0404. 04... _.h _.... _. Reimplantation C 3........ n.......... Removal of impactions C 3...._.. _. Stabilization C 3... u....._._....~.~:..~!.::~.~.:.~~:.~.~.~.i.~.~.: 9. _.}. Transplantation r: 1 Fixed appliances.... G. 3. Removable appliances C 3 PERIODONTICS Gingival Surgery C 3... _.._-_._.... -.... _. Osseous Surgery C 3 _ n _... ~.~.~.:.. ~~~~~~~ ;: <;; J. Scaling... C 3. Splinting C 3 PREVENTATIVE Fluorides C 3 Prophylaxis C 3. II PROSTHODONTIC, FIXED Sealants C 3 Bridges C 3... _._... _ -_....~.~~.~~: ~ _ J. lola s c
RESTORATIVE...~.:.~~.~:':.~ Q.... _1. _. Obturators c 3 Partial dentures C 3 Amalgam restorations C 3 _ _ u u. u _ _ Labial veneers C 3.. _ -.._..... _... u_... _. u Resin restorations C 3 TEMPOROMANDIBULAR TREATMENTS... ~.~.~.~~.~~=:.~......._ ~... 3.. Occlusal...._._ adjustment C 3. Reduction of dislocation C 3 OTHER Conscious sedation C 3 ---':"'/-i-) '-'::""(--=-C(--1- Lf 0_ CLlNI&IAN.r>: As Department Chair, I 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 appropriate.. I recommend approval of the requested privileges. clin_prlden R:07113/94