Effective s: 7/1/2014-6/30/2016
AHP Clinical Privileges Update Form.Janet Warren Department of Law Psych & Public Policy.iave 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. L.::}Obe ~L~~ I J ~';:P"'r= ~ ;;':it:"io~nllooee::r..!t's~s:"::i:":g:::::na:::"t";"u-r-e---------------- As the Supervising Physician/QI LiaisonlDepartment ChairlMedical 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 ~'pointment, Wehave reviewed applicable information from the following sources of quality and utilization data: ff Medical Record Review B'1\nnual Evaluation ~Continuing Education Conferences c:y"physical & Mental Health related to Job Performance [3'" Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ~ o Student Evaluation o Annual Review by Dept. Chair or SCA _ Acceptable review with recommendation of reappointment with clinical privileges as requested. o Concerns noted on review with corrective action plan in place with recommendation!- as requested. but subject to a review in months. b~ ei Mwyvi~1 fl"~-iy ~~ en ~ia", M.B. PkA. Primary Su~ing hyslcian Signature Printed Name J~~c", fi'u-~ Ph.() A.ulre8 B8Fi6~9wit!, Ph.D. Printed Name -t1!1uo of reappointment with privileges Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature (J 'tbj Il(} Clinical Care SV,' A ministrator (for Me employees) l Printed Name Printed Name Bankole Johnson, M.D., Chair Printed Name revised 3/1/2005
AHP Clinical Privileges Update Form,;;;::JaoJ tv~ Department of /..cu;; rtych '0 f6 blcg Ib/lW r nave reviewed the privileges previously granted (copy attached) to me and request the following changes: :W Privileges to be Added (please indicate category level and type of experience): I 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. / 7 ~2ak..tuJ PI' titioner's Signature As the Supervising Physician/QI Liaison/Department Chair/Medicnl 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 ~ypointment, we have reviewed applicable information from the following sources of quality and utilization data: u Medical Record Review [J/ Continuing Education Conferences u:;v'physical & Mental Health related to Job Performance [j]./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: ~cceptable review with recommendation of reappointment with clinical privileges as requested, o Concerns noted on review w~ corr tl ction plan in place with recommendation of reappointment with privileges as equested, but SUbjecti. :revie In onths, J.. l( O~ ' ~tt~te{ov ~~~~~~~CB~---- ~~~~~~~~~irttffi;:::?v)f7, rinted Name AltsFFlate Supe isillg Physician Signature-&I '41' So1t Printed Name kl- ett ' /bdaa c/l OW / f6f, Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name c.')../.js/~g Clinical Care inistrator (for Me employees) Printed Name 8a.n/wLe-.J~n>!JJ11 DSc,ft1lJ, Ph'/) Chair/RPC Med!9UJi1'9ctor Signature (for HSFemployees) Printed Name I revised3/1/2005
AHP Clinical Privileges Update Form ~~~ Department of Ltw. P.s'fch,,-;JcJo!ctj~ L~ rve reviewed the privileges previously granted (copy attached) to me and request the following changes~ ~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 Practitioner Databank. Practitioner's Signature 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 privi es) as related to requested privileges and agree that the above named AHP's qualifications are appropriate. Since the date of t appointment, we have reviewed applicable information from the following sources of quality and utilization data: I-c:-]..;j Medical Record Review Continuing Education Conferences Physical & Mental Health related to Job Performance Risk Management Events/Quality Management Reports for claims 'm oo Annual Evaluation Student Evaluation Annual Review by Dept. Chair or SCA o 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 privilege as requested, but subject to a review in months. IIa-tja!t '/ e ::l. :;;./. if'*" pervising Physician Signature ~~~~" 1'«7e~ AIt~ :;~ =si9nature nnted Name Printed Name Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name tr Administrator (for Medical Center employees) Printed Name Printed Name revised 1/8/2003
AHP Clinical Privileges Update Form h~e=previou:;:::::;:o/;~::;~ ~!:!:t~le:~:~~ges: -I 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.! 7 As the Supervising Physician/QI Liaison/Department ChairlMedical 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 ~ointment, we have reviewed applicable information from the following sources of quality and utilization data: o Medical Record Review Continuing Education Conferences Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims o Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA o 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, but subject to a review in months. Primary Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name.;(.;It o::r Q /a-d-) 05 ~ -., (for Medical Center employees) &.r~/cr<-! Printed Name ~&-Il Chair/Medical Directo~~re (for HSF employees) Printed Name to Ie.
AHP Clinical Privileges Update Form ~ ~ f.ja.m1 h Department of -,L--"C--"~-...::U--,,--,,,------.-J have reviewed the privileges previously granted (copy attached) to me and request the following changes: rew 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. 2 --- 'K - 200 3 As the Supervising Physician/Ql LiaisonlDepartment ChairfMedical 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: ~.------------------------------------------------------------------------------------------------, o Medical Record Review o Annual Evaluation Continuing Education Conferences Student Evaluation Physical & Mental Health related to Job Performance o Annual Review by Dept. Chair or SCA o Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing eduacation documentation required every 2 years) Other ------------------------------------------------------------------------------------ We find as follows: o 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. Primary Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name Alternate Supervising Physician Signature Printed Name Alterante Supervising Physician Signature Printed Name F employees) ~/c.v ( Co :Ii2wk~ ;:;H a Printed Name g. --S. Co n+erz-bu, RJ 4,----- Printed Name I revised 1/8/2003
Privilege List for: Licensed Clinical Social Worker Name: : _--'?=--Il~~o.o~<.-_ PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACfICEj EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WInCH YOU DO NOT REGULARLY PRACfICE. AREAS IN WInCH YOU DO NOT REGULARLY PRACfICE SHOULD BE LEFT BLANK. ACCORDING TO CATEGORY, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE: A B C D The applicant will not undertake patient management except in emergency. The applicant will manage patients with physician present. The applicant will manage patients in collaboration and/or consultation with the physician. The applicant will manage patients as an independent clinician function. General Individual Therapy - Adolescent General Coordination of Services General General General Diagnostic Interviews Couples Therapy Case Management General Biopsychosocial assessment General Individual Therapy - Adult General Group Therapy - Adult General Group Therapy - Adolescent General Information referral ~General Continuity of care planning General" Psychoeducational support groups OTHER PRIVILEGES. Neonatal Ped Adol Adult Geriatric r. (' 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. DATE J3.--c~~ Principal Supervising Physician Signature Name Printed E:>r~c.e...J:G~r\HD DATE Alternate Supervising Physician Signature Name Printed DAT,,-------DAT 5'p1jO~ Alternate Supervisi ~" S" em'" Adm;.;,,, Page 1 of 1