., Clinical Privileges Update Form Susan Modesitt Department of Obstetrics and 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 ofexperience): Current Privileges not to be Renewed:* ~~------------ ;*Privileges not renewed are not reported as being voluntarily reli~cjuished unless this is done while you are underinvestig~tion; 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. 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. 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: [1}~ 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 privileges granted but restricted as follows:, -- DA~;-- 2~~_~ -- ~lvlsl~1~n$;:il-~--~~~---~~ DATE?'~'(L DEPAROO~A~U~;:rr ~,Ii/. SIGNA~ Revised 3/112006

Clinical Privil{~gesUpdate Form U~RSITY C!!_ViRGINIA.Snsan Modesitt Department of bstetrics and Gy L- HEALTH SYsTEl\.1 ~ I have reviewed the privileges previously granted to me nd request the following changes to include any new therapies, procedures, or additional training ne essary to perform new privileges requested. (pleas e include supporting documentation to erify competency): New Privileges to be Added:(please indicate category le el 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; "--pr, in return for not conducting an lnvestlgatlon or proceeding. If privileges are to be reported as voluntarily relinquished you viii be notified and receive a copy of the report to be filed with the National Practitioner Databank. CLIN IAN S ATURE As the Division Head/QI Liaisen 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: ' We find as follows: G:::}'Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested D Concerns noted on review with correctlve action plan in place with recommendation of reappointment ~T~'~' to the,c, IInlca"lstaff,Withprivileges as requested, but subject to a rev,e:u", ' months. [] ~o): p,wlleges granted but res c d as foilow~ :;J( J(~~(Ol ~:ATE {.,I DIVISIONft~~~SI ~~~V_~~ )v~!/~-~:..oate DEPARTMENT CHAIR SIGNATURE _ Revised 3/1/2006

Clinical Privileges Update Form U~TJ:VERSITY --!!'-- o/virginif:l Susan Modesitt Department 0 Obstetrics and Gy.!!!HI. JiEALTH SYS1T ~J:vl I have reviewed the privileges previously granted to me nd request the following changes to include any new therapies, procedures, or additional training n cessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category Ie el and type of experience): Current Privileges not to be Renewed:* *Privilcges 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. C ICIAN SIGNATURE 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~ follows: ~ Acceptable 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 ~ ommendation of reappointment to the clinical staff with privileges as requested, but subject to are e n months. Should have clinical privileges granted but re DATE ATE Revised 31112006

Request for aser Privileges University of Vir inia Health System De artment of Ph sician Name: Please check those types of lasers that you a e requesting privileges for, and indicate type of training/experience. TYPE OF EXPERIENCE: 1 2 3 Comp ted Formal Training Limite Experience - without formal training Extensive Experience - without formal training PRIVILEGES, Laser Privileges Requested Type of Experience Laser Surgery - Argon r. c, Laser Surgery - CO2 I Laser Surgery - Holmium Laser Surgery - KTP 4- Laser Surgery - Pulsed C A- Laser Surgery - Yag A Laser Surgery - Lite Sheer f1 S;3I/o~, A --/U/2422~~LZ: Date 7 Clinicia~ure. As Division Head/QI 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 l-/y-ol.>..d A /1/1J Date 1approPriate., r e:. udlib l-13-0 lp Date <+;>~r-c>-b~ Department Chair Please return completed form to Clinical Staff Office, Box 800547. Rev 7(2003

REQUEST FOR CLINICAL PRIVILEGES Department of Obst tries and Gynecology University of Virginia ealth Sciences Center ~~~~~~~~~~~~~8 /o/~~~. ~~~~~~~~~~~~~"~~m~/?r~~ Year of Certification CJCO.L :...--- yeaf-of. Geftification --. -... -"... -'.'... -..--.. -.- Admitting Privileges? ) Yes 0 No Virginia Ambulatory Surgery Center Privileges? ~ Yes o No PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. According to category, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake patient management except in emergency. Category B The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. Category C The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. Type 1 Type 2. Type 3 According to type, enter 1, 2, or 3 (all that apply) in the EXPERIENCE column. Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training Ii GENERAL MEDICINE INFERTILITY Differential Diagnosis and Treatment c.. i :::~I~i.~~~::~~~:~:~~~~?:~=:::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::: :::::::::::::::~::::::::::::::::::::: Health maintenance f' I Immunization l ~ I Non-surgical evaluation and management l\ :::::::::::::::L:::~::::::::::::~:..._ ~.

GYNECOLOGY Antepartum care High risk e- I...f..L......_. ~;::::d:i:: risk ~ _ L. Birth control - counse ing and management c.. 1 E~ d ~~,: i ;~ E;~; i~a ti ~~ _. _ _ :::9.:~:~~~~~::~~~f.~~~~?~::::::~... C :::::~~:=~::::~::~:::~~~:::::::::::::::~:::::~ :::::::::::~:~~:::::::::::::::::: r ::::::::::::r:::::::::::::~:::::::::::...~~~!~~=..:.~~~.i.~.~.~!.~.~.._ ~.!.. Sexual counseling I u u _u. u u u u _ _ Subspecialty evaluation Endocrinology Oncology.. UroIOTc jiiiiiiiiiiiiiiw~jijiiiiiiiijiii Category Category A B According to category, 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. Category C The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. According to type, enter 1, 2, or 3 (a// that apply).in the EXPERIENCE column. Type 1 Type 2 Type 3 Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training Biopsy ~~ A Cervical ~ _ 1"". ::::~=:::::::::c.::~:::::::::::::::::~::i:~:::::::::::::::::::: Endometrial Vulvar...... ~... C. I.................. Conization of cervix C- I :::~::~::~::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::~:::::~:::::::::::::::::::::::::::::::::~:::::::~:~::::::~:::: ::::::::T::::~::::::::::::::::::::: General surgical procedures... _ - See Surgical _ _ -- A. Hysterosalpingogram i~;;;~ti~~~ c y ~~a i~ ~ t"i ; ~ -f-'t' 7. I t i;;ig~ti~..~ ~ ~ d d;~i~~g~ - - ~ 1...................................................... /'i......... '"......... Laparoscopy v 1 ~~r N ; ~ pi ~ ~t i~~ ~ rti ; ~ ~~d ~~ ~;;~~ i ~ I. _ _ _... u _ lc.

..._ Pap.._ Smear........._._..._..._.... U/S....: G. c.. 1.. INFERTILITY In vitro fertilization an related procedures I MATERNITY CARE/DELIVERY Amniocentesis Genetic.............. "... u h.,'... "', ','.,... :.u :. ~.!.,",. ~::I~dard :~~:::::::~:~::~:::::==:~: :::::::::::1::::::::::::::::::::::.-...-J---- -Bio~~~I~-- - --- -----~---- - ~~~~===~~=~: :.::..~:-:~ :;:~ ~ ~~~~~:~:;t;;hy ;~;= =,. - ~, - -..~ ': ' {-, '.................. Circumcision \ ::~:?!.~?~~:~:~:~~~~:::::::::::::=~:~:::::::::~:::::~:~:::~:~:=~:::::~::::::~::::::: ::~::::::::~:::~::::::::~~~:: :::~:::::::h.:::~:::::::::::::.. FHR.. ~;~ it;~i;:;g.. ~. Doppler velocimetry 1'\ 7- _ u _.nu Forceps Low-... _~~~:!: _ :~:::::::::::::~:::::::::::::::::: :=~::::~::::L:::::~:::::~::::: Intrapartum care ~i;~~i::iate risk : ~ i ~.... ~.?.~~!.~.:..~~~.~ It::.1...~~~~.?.~?..~~!~~.~~~ _... i...~~~~.~.~.::.!.~.: Lacerations repair 1st & 2nd degree../. 3rd degree & 1... 4th degree A:::. 1. ij g ~ti ~~ ~t~~i;:;~ b i;;d ~ ~ ppj"y.. r:;, r.. M ~ itipie g ~~t~ t i ;~ d-;;i i ~ ~;y.. _ {i;. - 1'. :~~:~~~~~;:::~~!~~:!~~:I!:~~~~::~:~:~:~~~y.~:::::~:~:::::::::::::~~::: :::::::::::::{I;::::::::::::::::::: ::::~~::::I:::::::::::::::::::::::::: St~~ ~~ t ~~t: fe-t;i..... :. NST. fetal ~. i -... n TransabdominallTranscervical CVS 1st trimester 2nd trimester 3rd trimester u/s Basic Vacuum Targeted

,, Vaginal delivery... continued Version ONCOLOGY Chemotherapy 1 SURGICAL :::~~~~~:~~~!!?:6~~~::~~~:~:~~~: ::::::~:::::::::::~:::::~::~:::::~~:::::::~:::::::: :::::::::::::::::~::::::::::::::::: :::::::::::L~:::::::::::::::::::: Radiation therapy (int cavitary implants) r: (. Unn _.. uu. u._...... n...... n...... u _.. n ~ u n...... Sur ical rocedures - ee Sur leal Abortion D & E: < 12 weeks. t-: \... _~~.~:;..~;._~t~~~;~~~;~:.~.~.~ _=:..=&~~~~~ =.:i.~:= :...~.~.!.:~!.?~..~.~.~p..?~~:.~.~~.~ "B;~ ~i"s ~ ~ g'~~y -,." _, ;- _.!..:!?~!~... L. Biopsy - needle, excisi n I Radical G.. Simple r- \ :::~~:~~:?:~:~~~~:~y~:::::~:::::::::::::::::::~::::::::::::::~=::::::::::::::::::::::::~::: ::~:::::::::::c::::::::::~::::: ::::~:::::::::.c:::::::::::::::~:::: _.~.?.~:.........~.1 "....~y.~.!?~.:~!?.y. ~.1....~..~..~ _ G. ]. _.. Debridement.... C -..E..i.~.:.~!~~~ ~y~.~.~~!!.~~!:.~..!?!.9.::.~.~:.:=~. c._. L_.. Drainage intra cavity. r / E~ d ~ ;;;~t~i~ i..~ b i~ti ; ~ - _." y.: _ 1 _ _ ' n n n~ u n Excision f' \ Fist ~i a ~e pa ir ib~~ ~i ~~d ~~i~~ ;yf - :t.. _ _ "j.._. :::~~:6:~!~:~:6:~!::~~~::~~_~~~~:~::~:~~:?:~:~~~~:::=:::::::~::::::~=:::::: ::~::::::::::::t~::::::::::::~::: :~::::::l:::::::::::::~:::::::::~:: Genital system (hysterectomy and related /' I procedures)... v r.... Hernia repair C-. \ :::8.y.:~!~:~:~~!~~y.::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::: ::::~:::::~::k:::::::::::::::::::~::~::.:[::::::::::::::::::::::~:. Incision and drainage r- { "i~f~-; t i ~ ~ d i ~C;~d;;~s - _ t.. _ r.. "..,,... _.... _..... (_. Intraperitoneal therapy /I ~ n In vitro fertilization & related procedures... ~ ~ 1j:?- _.\ _.._. Laparoscopic surgery '--- \ :::~~~:~~~::~:::::::~:::::::::::~:::::::::::::::::~::::::~:~~:::::::::::::::::::::::::::::~:::::::. :::::::::::::::::E.::::::::::~::: :::::::::.L:::~~::::::::::::::~::: Lymphadenectomy t: l _.. u ~......n...... n. Lysis of adhesions... _...... _.-.... _. Needle biopsy r L N ~ d ~ bic;p~y.. - _ (:: _ _ 1 _. O ~ ph ~ ~ ~~t~;;y p~ ~ ~~e ~ t~~i~.. -.......... t; ~...................................... Para-aortic and pelvic node dissection ('"i............... v

,... p;-~t~~p..~~ ~ ~ d..;;; ~~ ge;:;;~~t.. -.-.-.-~ - -r.l..-- _....... Pre/Antenatal - See aternity Care/Delivery :::~~~: '!~~~!6:~!'~p.y~::::::: ::::::~:~~~:~:::=:::~:~~::::::~~:::::=~::::~ :~::~=::::::5.~:::::::=:::: Radical pelvic surger (including bowel & :::=:::::~=~=~::~::=::~::....~Ei.~~.:.t...!~~.:~J _........ ~, ~. Retroperitoneal explo ation.. s~ ipi ~g-;;;-t ~ ~y L C...... \ \.... -....r...... t...... :::~~~~~~~t:~i~::::::~::::::::: Sigmoidostomy \...-- :::~:::=:=::~~::~::::=::~:::::::::=:::::::::::. ~::::::::::::~::ff::::::::::::::::::::::::~[::::~:::::::::::::::: u _ _ _ _ Urinary tract surgery... :..,'::'. '. :::',:'...,",' ~~~~=~.~ ::::::~:::::::::I:::~~::::. Simple.. -.-.. --, - C '\- ::::::::T:::::~::~:::::::::::::::: U/S abdominal and pelvic G-.. v ~gi ~ ai..~~..~t~ ~i ~ ~..p~;:;i~-p~ ~..~~ p ~ i ; (5. _ t,... Wide..e ~cisi;:;n..io~e ~..ge~ itat t ~ ~ct..ie ~i ~ ~ ~.... \". OTHER Catheterization C- \ :~~~:~~~~~~~:::~~~:~~!:~:6::::::::::::::::::~:::::::~:::::::~:::::::::::::::::::::::::::: :~:::::::::::::::::~~::::~:::::: :~:~:]~:::~::::::::::::::::::::::.. Cy~t~~~py........ - _,...... C _.... y _.. _ _.. E ~ d ;;-t ~ ~~h~ ~ i..i~ t~ b ~ti ; ~...... )S(. Placement central IV access lines :::~!~:~~!~~~~:?:~y.:::::::::::::~::::::::~:::::::::::::::::::~::::=:::::::~::::~:::::::: ::::::~::::::~:::::::::..:::::::::::::::::~::::~::::~::::::::::::::: Swan Ganz catheter placement..f\.., b :::Q!.:~::::::::~:::::::~:::::::~::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::: ::::::::::::::::~:::::::c.::::: ::::~::.I=:::::::~:::::::::::::: j T'~a???~4 cu ClAN /------ As Division Head/QI Liaison and Department Chair, we 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. The following indicators have been reviewed for reappointment.

Since the date of the last appointment, we hav following sources of quality data: reviewed applicable information from the o Physician's Health & Mental Status o Inpatient Attending Performance Morbidity and Mortality Reports o Blood Usage Reports o Drug Usage Reports o Infection Reports o Invasive/Non-Invasive Procedures o Medical Hecords Documentation We 'find as follows: o atient/family Satisfaction o entinel Events/Risk Management Reports o onsultation Attending Performance Outpatient Clinical Practice o rher: reer Review of Clinical.. Performance o I o Acceptable review with recommendation of ~ointment 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. DATE DATE DEPA TMENT CHAIR clin_pri.obg R:04/11/97