02/22/2011 10:46 FAX 434 982 6275 HS/CS ~001 Carlos ClIP_IfrMJ., Update "rna I... reviewed tlat privilq&a p~,ruted to me and requcat t'e touowlq cuna- to laelude any bew timrapi.,.. proadu.""or additional traibui, ecanary 10 pedorm Dew privil... requeated. (P...Include su.pportidi doeuldedtation to veri(y oompetellcy); New Privilepl to be Added (p...sndlea1:e a-.lory le d aad type of' aped..ee): -----"-------,..._--.,._... -~,-..-----------. -".".-~--.-.---------- ---------~---"."..,------------ _.,_._.2. - rj - ( \ nate M thedi'rilloa HeldlQI LUI_aad..,...eDtClaalr/MecUc:a1 Dlnctor. we bve reviewed tbe v....med dldlelall.iftei0'~ p.st perform...ad quiit)' iiad1atun (lfnd..iii& 'ml...>..... to... prtri...~tjam..aimw. eadmd cuowaa t,...tloaa...ppz'op... Since the d.,. of,hetut lppohltmeat, '" ha"t I't' Iewed a~ieab"l.fond.tld8 from Che foilowhlllountl of qualtcy arid _til_tidn da1b: We thki..followl: j%j AcQeplilbla..."1"with rwcommendatiorl qfnmlppolntment to the cdlnlgiii etaff wf1h dlnlcij prlvllllilflm" reqlmtlad =.J Conceme noted on nnriew whh oomotlve fttion plan In pile. with raoommendatlon of reappointmant to the cllnicai.ta«with prmi8g... req...d, but.ubjectto a...new In _ monu.. o ""-----...-~ _--IIf...fr~. ~ DlVISlON IIEADfQI LIAISOPI SIGNA 11JRE ---, \~~-----,---,--~ DEPABTM1NT CHAIR S1GNAl1JR1t

Clinical Privileg;es Update Form Carlos Tache-Leon Department of Surgery I have reviewed the privileges previously granted to me aud 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:'" -------------------------_....._._ j*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. Ifprivileges are to be reported as voluntarily relinquished you lwill be notified and receive a copy of the report to be filed with the National Practitioner Databan DATE - ( --_._- 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 find as follows: D 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. Should have clinical privilege. granted bul...ricled ~ -.--llfi~ ((..._... YfK---._ DATE DIVISION HEAD/QI LIAISON SIGNATURE DATE DEPARTMENT CHAIR SIGNATURE Revised 3/112006

r Request for Laser Privileges University of Virginia Health System Division of : Please check those types of lasers that you are requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: 1 Completed Formal Training 2 Limited Experience - without formal training 3 Extensive Experience - without formal training PRIVILEGES Laser Privile2es Reques.ted Type of Experience ;./ Laser Surgery - Argon I Laser Surgery - CO2 Laser Surgery - Holmium Laser Surgery - KTP Laser Surgery - Pulsed C,.-, Laser Surgery - Yag /'~ Laser Surgery - Lite Sheer.----~ S~(re-20(O (D/i ") Date -...abieiall's Slgnalure As Division HeadlQI Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree that the clinician's qualifications are appropriate. Date J(2':> t!q Date {. ~eadlqi Liaison Department Chair Please return completed form to Clinical Staff Office, Box 800547. Rev 7/2003