AHP Clinical Privileges UPdate Form ORIGINAL Jan Ekberg-Shelley, CRNA Department of Anesthesiology I have reviewed the privileges previously granted (ropy attached) to me aod request the followiog changes; Ne'! Privileges to be Added (please indicate category level and type of experience): Cgrrent Privileges not tg!>erenewed: * *Privileges not renewed are not reported., beidi voluntarily relinqulthilld linlnl this isdone wbile you are under illyestigation; or, in I'ftIIrn for not conductine an Investlption or proceeding. If vrivileges are to be (eported as voluntarily relinquished )'00 will be ootified a receive a copy or tfle report to be filed with the National Practitioner Databank. ---'-.~.' ~ As the Supervising Physlcian/QI LiaisonlDepartment Cbalr/Medical Dir' I Service cenil Admini8tr~ftVe 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 appoldtmen~ we h.ve reviewed applicable information from the following sources of quality and utili2>ation data: ~/Medicill Record Review Annual Evaluation [B' Continuing Education Conferences Student Evaluation [;I',,,Pbysical & Mental Health related to Job Performance o Annual Review by Dept. Chair or SC 8 Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Othet ~~ _ We fidd as follows: ~CCePtlible review with recommendation of reappoinbnent with clinical privileges as requb8wd. o Cone.me noted on review with COtTectlve action plan In place with recommendation of reappointm.nt with privilea.~-",.qu ted.:but t to vfew In month ' ~12ir O(, o.te Barbara Castro. M.D. Printed Name Geo e Rich M.D. Printed Name A1temate Supervlelng P~le"l'l Signature Printed Name A1tematelj;rvlS'zyjlan s.,gnature. f','-' LV- I Clinical Care SVC8 Admlnl.trator (forme employeh) Printed Name a Via Admlnlattator Printed Name Ch.'r/RPC Medical Director Signature (forhsfamployeet) prtnted Name revised 3/112005 ld Wtl S:L0 600c PC '5nB 'ON XIj.:;j WOtt:l

AHP Clinical Privileges Update Form ~( Department of Or?- /-}li.;:y{j.l~to/c;s ~ L ------1have reviewed the priv es previous granted (copy attached) to me and request the following chang's: 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. ~e~el--jwo,-- As the Supervising PhysicianlQI LiaisoniDepartment Chair/Medical Director/ Service Center Administrator, we have reviewed the above-named AJIP'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:,f1' Medical Record Review ~ Continuing Education Conferences g Physical & Mental Health related to Job Performance ~.Risk Management Events/Quality Management Reports for claims!b" Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA G Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ------------------------------------------------------------------------------------ We,d asfollows: 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, ~ect to a review in C;. months. '-------::::> C --.l.l) '5\o:t- ~~'-. _~ )0~\O~ ~~(Z() Primary Supe. ng ysician Signature Printed Name \11~/J~ ~ beqr~ e~ci.,~ I Dale. ate Supervising Physician Sig ture Printed ame Alternate Supervising Physician Signature Printed Name L-Llr~La}: Printed Name Jrr1 D, Clinical are ves Administrator (for MCemployees) Printed Name ti~m Chair/RPC Medical Director Signature (for HSF employees) Printed Name revised 3/1/2005

AHP Clinical Privileges Update Form -,-,-",~-=-=~~~~.. _S_~fn~ntor~- 19N..6~;"{ClA\ I ~ave reviewed the privilege viously granted (copy attached) to me and request the fofrolwin~ changes: IV 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. \Lb-l,-!-L-C ~- --- (' --~~~~~~~~~~~~~~~~+-- As the Supervising Physician/QI Liaison/Department 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: Ii Medical Record Review '-G1' Continuing Education Conferences j Physical & Mental Health related to Job Performance g/ Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA 19' Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other ------------------------------------------------------------------------------------. We find as 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, b E:..\ g I (G:bSt/!?/t7f rvising Physician Signature Alternate Supervising Physician Signature Printed Name I Printed Name ';;;:~AJ..c~ Printed Name Chair/Medical Director Signature (for HSF employees) Printed Name revised1/8/2003

AHP Clinical Privileges Update Form ~~~~~..!X-~~(e.'::::::f-. Department of ~{../u.s;o{ <9kylOR. I have reviewed the privileg reviously g anted (copy attached) to me and request the foll~ing 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. ~\~U~Q2 ~~\~... ~~~~~~~~~ ~ \ Pr3:c}itioner's Signature As the Supervising Physician/QI Liaisonmepa~tmeri't ChairlMedical Director Se ice 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: Medical Record Review Ii Continuing Education Conferences ri Physical & Mental Health related to Job Performance I2f Risk Management Events/Quality Management Reports for claims g Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA oj Prescriptive Privileges (8 hours continuing eduacation 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, but subject to a review in onths. b ysician Signature ReVlsed 11/19/2002

HCP Clinical Privileges Update Form.~ --=~~!Il--=~~<..:::f-Department of 0jb\ - A ~+~ l0 16<s'-...l have reviewed the prtvi ges previousl granted (copy attached) to me and request the followlnj 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 COP)' of the report to be filed with the National Practitioner Databank. As the Supervising Physician/QI Liaison/ Department ChairlMei IDirector/ Service Center Administrator, we have reviewed the above-named HCP's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named HCP'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 HCP's Health and Mental Status Continuing Education Conferences Sentinel Events/Risk Management Reports o We find ayrollows: ' &;(' 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 subjecc a :;view in month, '" (,». (. '-~-J..,c V \).\1-l~Dl (2--( 2--rf0 f Se ician Signature Collaborating Physician Signature 2r ~ 0/ Revised 031211200

~Urivilege 07"an-OO List for CRNAs JD.O ~~~k:l[e..y : ~\ 1:\\ 7 ffo! t ( - Name: 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 ~ (Circle One) You must have a current Authorization to Prescribe to do so. c..~ ACCORDING TO CATEGORY. ENTER A. B. C. or D IN THE COLUMNS NEXT TO THE LISTED PRIVILEGE: A The appucant will not undertake patient management except In emergency. B The appucant will manage patients with phystclan present. C The appucant will manage patients In collaboration and/or consultation with the physician. D--'The-a-ppUcant will manage patients as an Independent Nursing Function. (These privileges are activities not specific to the nurse -pmlctitioners. Any basic RN can pe rform them. General Medical Medical Medical ------- \1edical ~- Medical Level of Supervision Privilege: Neonat Peds Adol Adult Oeriat Authorized to Prescribe I Anesthesia Care Plan L c.. c (' C Post Anesthesia Evaluation C C r C' C Post Anesthesia Mgt c c.. c. C- C Preanesthetic Consent C- C c. cj C Preanesthetic Evaluation C. L. C- elt Airway Mgt - Bronchoscopy & Intubation, Fiber Opt c c, C c., C Airway Mgt - Combi-tubes C C C C C Airway Mgt - Laryngeal Mask Airways C C. c.. cj C, Airway Mgt - Laryngoscopy C- C- C- C- C Airway Mgt - Mask Ventilation C- L <., C C Airway Mgt - Percutaneous Tracheostomy A A F\- A A- Anesthesia - Caudal Blocks (7 K R R (-2, Anesthesia - Digital Blocks c.. L C- L- (- Anesthesia - Epidural Blocks & Catheter Place/v- u:"'~yo..' C c., C C C Anesthesia - General, Inhalation C- C- C- C CJ. Anesthesia - IV Blocks C- C::.- C- c C.- Anesthesia - Peripheral Nerve Blocks C C c: c.. C Anesthesia - Subarachnoid Blocks & Catheter Place. C C C C C- Anesthesia - Subcutaneous r: C- C- C C- Anesthesia - Topicalization of Airway r C. C- c. C Anesthesia - Transtracheal Blocks C- c., C- c., c: Anesthesia Local ( c. C c c. Anesthesia Regional c. G C- c.. c. Arterial line placement C-- G C- C- C Blood Product Administration ~ tj b J) \) Cath Swan Ganz catheter placement 4- f:y r-- c.. r+ 1

DO_ m_~_et_i_0_c)_~_::d:f)~:s~==== Level of Supervision Privilege: Neonat Peds Adol Adult Gertat Catheter - IV Peripheral - Placement & Mgt 1) \J \) h D Catheters - Central Venous Pressure A C C- c: r: Endotracheal Intubation Ie...x:..~'\ b~ G\r\ c, C c, c., r Injections - Intravenous, Gen'l Anesthesia / m o.c.- c C- r: C'.. < Med Administration - Epidural C C C r C- Med Administration - Intrathecal C c. c.. c, r Med Administration - Oral / ('"e..r1-n. \ I\(l\ ~.D f' Med Administration - Topical \) \) \' [ OTHERPRnnLEGES ;10 - f,vv)?x-&~~ h_s:_s_u:5_c_~'tfl_~_' ill3j2ctt.2 d:'2lth ~,\0 Sl. DAl!E ~A'SSIGNATUR~"\ As the Supervising Physician and Department ChairfMedical Director, we have reviewed thelabove-named certified registered nurse practitioner's level of experience, past pe orrnance and quality indicators (if renewing privileges) as related to requested privileges and agree t the above named CRNA's quali(fi(lc, ~ti!:n::re appropriate. We recommend approv th r ested Privi,ege'll rt\. DATE I..~ ~--+f.hi./-_\~\j~j"-j_'- -..~ f'1f&ll~ G PHYSICIAN SIGNATURE DATE '13 L00 ji 2