AHP Clinical Privileges Update Form Gary Cuccia, CRNA Department of Anesthesiology. I have reviewed the privileges previously granted (copy attached) to me and request the following changes: New Privileges to be Added (please indicate catego level and type of experience): Current Privileges not to be renewed: * *Pri~ileges 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 0 be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner ata ank. 8 \ \'1; \1-0 091,--_ \ j As the Supervising Physician/QI LiaisonlDepartment ChairlM ical Direc or/ Service Center Administrator, we have reviewed the above-named AHP's level of experience, past perf mance 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,-. appointment, we have reviewed applicable information from the following sources of quality and utilization data: Medical Record Review Continuing Education Conferences ~ Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ------------------------------------------------------------------------------------ We find as follows: ri Acceptable review 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 as requested, but subl to review in mo s. ~ ~141()~ ~ Barbara Castro, M.D. George Rich, M.D. Alternate Supervising Physician Signature Alternat(1j~~rr::Signature Clinical Care Svcs Adminis-:-tra-t:-o-r (-fo-r-m-c-e-m-pl-oy-e-es-) Donna Via, Administrator Chair/RPC Medical Director Signature (for HSF employees) printed Name revised 3/1/2005

,G0r;t AHP Clinical Privileges Update Form lliu(t'-- Department of QA- 4ru.ssIkss{% '1 have ryiewed the privileges previously granted (copy attached) to me and request the following chan 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 unlessthis is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privi s are to be reported as voluntarily relinquished you will be notified and receivea copy of the report to be filed with the National Practiti ner bank. \~L6\01 "\ \ ~P:r:ac=t~it~I~O~i7~lg~n~at7.cte~r---~~~~-=~--------------- ---_, As the Supervising Physician/QI Liaison/Department JirlMediCa irectori Service Center Administrator, we have reviewed the above-named AHP's level of experience, pa~t/performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above najjd AHP'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 Record Review Continuing Education Conferences ~ Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA e1 E1 Physical & Mental Health related to Job Performance ~L Risk Management Events/Quality Management Reports for claims '--l Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: d Acceptable review 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 as requested, bu~o a review In ~ths' --:? C-~ ~ \~ \ )~ \ 0 >1-, O-?-''-~ ~r='lij \0O-\L~~,(\ljltfc) Primary Supe. ng Physician Signa ure \\/lnlt>1 b cy~ ~'e-h. MD Alternate Supervising Physician Signature llll")lo 1- Clinical J J A vltl( o. ~ta1 Chair/RPC Medical Director Signature (for HSF employees) ----------- ----- -------- revised3/1/2005

Gant (1.e~Q.. Department of Of?- J"--"avereviewed the privileges previously granted (copy attached) to me and request the fo 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 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 the report to be filed with National Practitioner Databank. \ As the Supervising Physician/QI Liai on/departm nt Chair/Medical 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: edical Record Review YK'ontinuing Education Conferences 0 Student Evaluation YAhysical & Mental Health related to Job Performance 0 Annual Review by Dept. Chair or SCA i k Management Events/Quality Management Reports for claims. rescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) ~ at r _. We find as follows: Acceptable review with recommendation of reappointment with clinical privileges as requested. e ising Physician Signature ~""'JL.' :D4JltJ 3D6-{)D~fC' Cq'::, "t--ffi Alternate Supervising Physician Signature t1 O~~C revised 1/8/2003

AHP Clinical Privileges Update Form ~ L1~ Department of - lof. I have rev ewed the privileges previously granted (copy attached) to me and request the following cha ~ew 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 will be notified and receive a copy of the report to be filed with the National Practl ioner Databank. As the Supervising Physician/QI LiaisoniDepartme t ChairlM ical Director/ Service Center Administrator, we have reviewed the above-named AHP's level of experienc, 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 appointment, we have reviewed applicable information from the following sources of quality and utilization data: Medical Record Review g--'annual Evaluation XContinuing Education Conferences 0' Physical & Mental Health related to Job Performance Risk Management Events/Quality Management Reports for claims Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) o Student Evaluation o Annual Review by Dept. Chair or SCA ther ------------------------------------------------------------------------------------ We fi~s follows: ~ Acceptable review 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 as requested, but subject to a review in months. ~,~~bj~o~j------- 1''). f((j;; -'-------- l.=--.. ~ ~ gp...,3' ratu re Revised 1111912002

HCP Clinical Privileges Update Form ~ Gnr:-i ~ Department of De- ~~ICL have reviewed the privileges previously granted (copy attached) 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: * *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 the report to be filed with the National Practitioner Databank. ~ r.,('kv1 Supervising As the Physician/QI Liaison/ Depart edical Director/ Service Center Administrator, we have reviewed the above-named HCP's level of experie,past performance and quality indicators (if renewing privileges) as ~lated to requested privileges and agree that the above named HCP's qualifications are appropriate. Since the date of the.t appointment, we have reviewed applicable information from the following sou~,?es of quality and utilization data: Medical Record Review &"". HCP's Health and Mental Status Continuing Education Conferences Sentinel EventslRisk Management Reports o We find a~lows:. n;/ Acceptable review 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 as requested, but subject to a review in months.,') -- ~/ Collaborating Physictan Signature CQ;in g PhYS::S Signatu" 7 ' I C' edi~cto, Signatu,. Revised 03/211200

-"lrivilege 07..Jan-OO List for CRNAs Name:. GJ. Ct4 t CVMt~ : ~ldq \ _ PLEASE MARK AS REQUESTED ONLY THOSE AREAS IN WHICH YOU REQUEST PRIVILEGES AND NOTE LEVEL OF SUPERVISION IN THOSE AREAS. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. Are you requesting privileges to prescribe? YES Or~(Circle One) You must have a current Authorization to Prescribe to do so. ACCORDING TO CATEGOR. ENTER A. B. C. or 0 IN THE COLUMNS NEXT TO THE LISTED PRIVILEGE: A The applicant will not undertake patient management except In emergency. B The appucant will manage patients with physician present. C The applicant will manage patlents In couaboration and/or consultation with the physician. D The applicantwill mluulgl!'patients as an Independent Nursing Function. (These privifeges are activities not specific to the nurse practitioners. Any b. 1cRN can perform them. General Medical Medical Medical edical Medical,r-, -cedure vvl ~ Level of Supervision Privilege' Neons t Peds Ad 0I Adult Ge' ns t Authorized to Prescribe Anesthesia Care Plan 0./ ~ _7) Post Anesthesia Evaluation ~l/ \. '-'"7'-) "-...L Post Anesthesia Mgt C--= -»: '-' '-'7 V, Preanesthetic Consent I r/~ - r v ~ c- " Preanesthetic Evaluation (\ / L L././ ----:-p,/ ",'../-v./ Airway Mgt - Bronchoscopy & Intubation, Fiber Opt (' -. '-.., Airway Mgt - Cornbi-tubes ~~ / \./ \../... I.,,--<- Airway Mgt - Laryngeal Mask Airways r_ ' / "--'"....... Airway Mgt - Laryngoscopy Airway Mgt - Mask Ventilation \:'\' -- t /' /', r-;,. P L. <;» ""'7 \...-.../ r/»: /' ';;:>. '-./ '-/ '\...- \../ Airway Mgt - Percutaneous Tracheostomy Iv ry {" r (' _ Anesthesia - Caudal Blocks t"./ Anesthesia - Digital Blocks "":) f... Anesthesia - Epidural Blocks & Catheter Place, C c- Anesthesia - General. Inhalation ( - r> 1\ Anesthesia - IV Blocks r> Anesthesia - Peripheral Nerve Blocks r - -;>. Anesthesia - Subarachnoid Blocks & Catheter Place. Anesthesia - Subcutaneous Anesthesia - Topicalization of Airway i- ) I l..--' -,7 Anesthesia - Transtracheal Blocks r ~ Anesthesia Local t> Anesthesia Regional (1 -~ Arterial line placement,-- - I> Blood Product Administration ( \ 'f::7 Cath Swan Ganz catheter placement If- - 1ft \../ t> (-'1'/ b I

Level of Supervision Privilege: Neonat Peds Ado! Adult G.:riat OTHER PRIVILEGES Catheter - IV Peripheral - Placement & Mgt r --;:::,. Catheters - Central Venous Pressure (' - - "> Endotracheal Intubation ('f- -'""") Injections - Intravenous, Gen'l Anesthesia (1.--., Med Administration - Epidural (' Med Administration - Intrathecal C.- Med Administration - Oral r I "7 Med Administration - Topical ( :-:> DATE As the Supervising Physician and Department ChairfMedi Directo we have reviewed the above-named certified registered nurse practitioner's level of experience, past performance and quality indicators (if renewing privileges) as related to requestedprivileges and agree that the above n med CRNA's qualifications are appropriate. We recommend approval of the requ ted pri s DATE DATE 2