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AHP Clinical Privileges Update Form Patrice Neese Department of Surgery I 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): nont. (no (:.I)a.nrrs) Current Privileges not to be renewed: * "Privil~ges'n!>t renewed arenot reported as being voluntarily relinquished unless this is done ~hhe you are under investigation; or, in return for not co.nductingan investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and rec!livea~<>py <>tthe rep<>rtt<> be filed with the NationIJ1Prac~itionerDatabank. Dat,e Practitioner's Signature As the,supervising 'Pl.tysici;m/QI--Liaison/Departmeat Chairl 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 AliP.'s qualifications are appropriate. Since the date of the last appointment,,,,e ban reviewed applicable information from the following sources of quality and utilization data: csf Record Review,~Colltin, ;nged~cationconferences _ '. ~'iphysica)f.&melltal_ Health related-tc.job Performance. ' ' &'JRlsk-Management Events/QwiHty Management Reports for claims Annual Evaluation o -_Student Evaluation ~-._ AnnualReview by Dept.Chairor SeA W'Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other,' ' We find' as follows:, ' 6 cep~bler~vi'~wwithrecommel'ldationof reappointment with clinical privilegesa$ requested, William Grosh, M.D. Printed Name Geoffrey Weiss, M.D. Printed Name Anneke Schroen,M.D Printed Name rft~ '\I, - vcs Administrator (formc employees) Printed Name ~ Date Irving Kron, M.D.. Chair Chair/RPC Director Signature (for HSFemployees) Printed Name revised 3/1/2005

AHP Clinical Privileges Update Form _;t:...--l(;::::-f~rt_cl-=-_m_~-=..-=.u..~._ ~_Department Of_~--=-CL---=--~{C:::::...~~=--d_hC. ;--==-~_O~'i--- - T have reviewed the privileges previously granted (copy attached) to me a equest 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 Practitioner Databank. Date Practitioner's Signature As the Supervising Physician/QI Liaison/Department Chair/ 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 qualiflcations are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: 3"' Record Review []/ Annual Evaluation ~ Continuing Education Conferences o Student Evaluation ~ Physical & Mental Health related to Job Performance'. ~ Annual Review by Dept. Chair or SCA D.Risk Management Events/Quality Management Reports for claims [91Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ------------------------------------------------------------------------------------ We find as follows: ~AccePtable review with recommendation of reappointment with clinical privileges as requested. ( Date Chair/RPC Director Signature (for HSF employees) Printed Name revised 3/1/2005

AHP Clinical Privileges Update Form fo1r( ~;.J ~&--- Department of----'~=u~-:a--'~:::.--::=_~~~~~~- '----::.ve reviewed the privileges previously granted (copy attached) to me an r quest 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. rk/o7- j Date Practitioner's Signature As the Supervising PhysicianlQI LiaisonlDepartment Chair/ 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, we have reviewed applicable information from the following sources of quality and utilization data: Record Review Annual Evaluation B Continuing Education Conferences o Student Evaluation IJfA ~ Physical & Mental Health related to Job Performance ~ Annual Review by Dept. Chair or SeA r.j Risk Management Events/Quality Management Reports for claims 0' Prescriptive Privileges (8 hours continuing education 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 ::droi;;questgd. butsubiec'(]r..:'. months. CR"":i-,.r<& ~ -Lrldate Primary Supervisi PrintedUame U-'-'------- 3ir Or<l::=t- -----:7 / in ~(iyo~ ~. Date,!iDI07 ~ Date /-~.-±Jr 0 l 0"'-r rip' te 1/ t tl07 Date Printed Name Printed Name j\tjisac S:eF-fKO~ Printed Name Itvv1'd Printed Name ~Y0IhS Printed Name tf,~'7/: kroa) revised3/1/2005

AHP Clinical Privileges Update Form /"-~have reviewed the privileges previously granted (copy attached) to me a equest 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 Practitioner Databank. -:r/i 3/0 c" ~ ~ )J~ Date Practitioner's Signature As the Supervising Physician/QI Liaison/Department Chair/ 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: ~ Record Review [B" Annual Evaluation o Student Evaluation />J / f'\ cg/annual Review by Dept. Chair or SCA ffii Continuing Education Conferences ~ Physical & Mental Health related to Job Performance iii".risk Management Events/Quality Management Reports for claims 0:( Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Ofuer _ We find as follows: ~ Acceptable review with recommendation of reappointment with clinical privileges as requested. lth corrective action plan in place with recommendation of reappointment with privileges t)- ~Name re. w in months. G. L. ~c.r',!f.:' ~~/; ' /7/&'1, /""7 Printed Name 6kJ 0.. &tb tjj!4arn. Printed Name Printed Name date Clinical CC#eSvc Printed Name Date Chair/RPC Medi Printed Name revised 3/1/2005

AHP Clinical Privileges Update Form /PJn ~~ Department Of_~~~~=..:~~~~~...k...'::;~~ _ ~ have reviewed the privileges previously granted (copy attached) to me an req s,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. Date Practitioner's Signature 0' Record Review ~ Continuing Education Conferences [0 Physical & Mental Health related to Job Performance ~ Risk Management Events/Quality Management Reports for claims ~ Annual Evaluation o Student Evaluation fo.j /4 cg/ Annual Review by Dept. Chair or SCA {2( Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other _ We find as follows: 0'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 t a eview in months. 7/ ' 1--/.o J Date ::r(('b-[ o~ Date Printed Name n Signature c..jv:v-" Printed Name Alternate Supervising Physician Signature Printed Name ~linical Care Svcs Administrator (for MCemployees) Printed Name Date Chair/RPC Director Signature (for HSFemployees) Printed Name revised 3/1/2005

Privilege List for: Adult Nurse Practitioner ~. 22-Jun-05 Date: 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 THE CATEGORY BELOW, ENTER A, B, OR C IN THE COLUMN NEXT TO THE LISTED PRIVILEGE A The applicant will not undertake patient management except in emergency. B The applicant will manage patients with physician present. C The applicant will manage patients in collaboration and/or consultation with the physician. ~rrocedure 'rocedure ~'rocedure.'rocedure Anesthesia Regional Pulmonary Function Testss EMG Audiometry Slit Lamp Exam Spirometry PAP Smear EMG Biofeedback Arthrocentesis Thoracentesis CPR Endotracheal Intubation Breath Hydrogen Test Osteoarthritis Rheumatoid Arthritis Rheumatic Fever - Acute Neurodegenerative Disorders Neurological Psychophysiologic Pulmonary Hepatic Med Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Dif Dx & Tx Diseases Dif Dx & Tx Gynecologic Routine Dif Dx & Tx Infectious HIV, AIDS Disease Dif Dx & Tx Electrolyte & Water Balance Pituitary Conditions Drug Reaction CVA Rehab & Overdose Foreign Body Removal- Vagina Rheumatic Heart Disease Wound Wound Wound Wound Histamine Mgt - Debridement Mgt - Closure Mgt - Dressing Mgt - Immobilization Provocation Wound Mgt - Removal of Sutures/Staples Urologic Disease - Dif Dx & Tx Impotence - Evaluation & Mgt Dx, Assessment & Mgt Neonatal Ped Adol Adult Geriatric c. c c c c c c Page 1 of 4

/~ ;eneral ~urocedure.jeneral ~, rocedure Patient Education Rheumatic Heart Disease Admissions Order Consults (with MD collaboration) Ventilator Weaning Mgt Nutritional Status - Eval & Mgt Contraceptive Counseling Cerumen Impaction Removal Chemotherapy - PO/IV/Intrathecal Peripheral Central Venous Line Placement Lab Test - Dipstick Lab Test - Cervical Lab Test - Urethral Lab Test - Rectal Urinalysis Cultures Cultures Cultures Surgical Drain Removal Wound Microscope Mgt - Electrocoagulation Eval - Urine Microscope Eval - Vaginal Secretions Microscope Eval - Post Coital Cervical Mucous Urodynamic Studies - Urodynamic Catheterization Gouty Arthritis Heme/One Dif Dx & Tx Spinal Shock - Mgt Urticaria Adjust Pacemaker Settings Camino Bolt Removal TPN Ordering Ventriculostomy Catheter Removal Adjust Cardiac Assist Devices Order Order- - Echocardiogram EEG Foreign Body Removal- Nasal Serum Evaluate Evaluate Sickness - Echocardiogram - Radiographs Evaluate - Urodynamic Studies Pulmonary Artery Catheter Manipulation Paracentesis Foreign Body Removal - External auditory Typanometry Wound Mgt - Wound preparation Cholecystitis Epicardial Pacing Wire Removal Foreign Body Removal - Subungual Ornaya Reservoir Wound Mgt - Assess for Functional Integrity Intracardiac Catheter Removal Hansel Smear - Nasal Secretions Geriatric Dif Dx & Tx Ambulatory Halux 02 Saturation Thrombophlebitis Pulmonary Artery Catheter removal Cirrhosis Infertility Initial Eval & Mgt Arterial Bone Marrow Authorized Blood Gas Aspiration to Prescribe Microscope Eval - Breast Discharge Neonatal Ped Adol Adult Geriatric G c: c. r C c. c.. C. c, Page 2 of 4

~ ~ ~1:edical.vledical Dermatomyositis Pancreatitis Lumbar Puncture Foreign Body Removal - Subcutaneous Order - Radiographs Order - Holter Monitoring Order- ECG Surgical Assist Lab Test - Blood Cultures - Draw Lab Test - Soft Tissue Site Cultures Order Medications Lab Test - Throat CNS Infections Cultures History and Physical. Transtracheal Aspiration Lab Test - Vaginal Cultures Health Maintenance & Disease Prevention Intradermal Skin Testing Chest Tubes - Clamp and/or Remove Immunization Sigmoidoscopy ICP Adjust Treatment Protocols Urodynamic Studies - PercutaneousEMG Allergen Immunotherapy Urodynamic Studies - Rectal Tube Insertion Urodynamic Studies - Simple Office Cystometrics Intermittent Catheterization Tx Tracheostomy Tubes - Remove Order - Urodynamic Studies Telephone Hospital Triage/Consultation Rounds Pain Management Evaluate - Holter Monitoring Cardiac Rehab Tonometry RheumatologicNasc Evaluate - EEG Renal Dif Dx & Tx Anesthesia Local Endocrine/Metabolic Evaluate - ECG Dif Dx & Tx Dif Dx & Tx. Allergy/Immun DifDx & Tx Cardiovascular Dif Dx & Tx Order - Labs Diabetes Mellitus Incision/Drainage Dermatologic Anoscopy Evaluate Percutaneous - Labs of Abscesses Diseases - Dx & Tx Skin Testing GI Disease Dif Dx & Tx Nephrotic Disease DifDx & Tx Pre and Post-Op Cardiac Care Head & Spinal Malabsorption Arthritis Immunodeficiency Health Maintenance Cord Injury Neonatal Ped Adol Adult Geriatric c, C- c c... c c. c. C G C c.. C C C C- C. C- c.. C c. c Page 3 of 4'

~ Sexual Counseling Fractures & Dislocations Skin Laceration Repair Norplant Insertion & Removal Nail Avulsion IUD Insertion & Removal Pessary Insertion & Removal Condyloma Tx's Conscious Sedation Diaphragm Fitting Biopsy/Removal - Skin Lesions Ortho s - Nasal Ortho s - Ribs - Stable Chest Ortho s - Shoulder Dislocation Ortho s - Clavicle Ortho s - Upper Extremities Ortho s - Lower Extremities Ortho s - Lower Extremities Rheumatic Heart Disease OTHER PRIVILEGES fi1q.ntjaa I~mpb clra..(~ COtnprC $ j,, ba.<-.dae1'''$ Neonatal Ped Adol Adult Geriatric ~~G~G ad~~~~~~ (~~~~~~o~~~~~~~'~~~\es~)*. ~ c. c, DATE Signature Pa.Jrj'_e.. Y. t\..iees~ Name Printed As the Collaborating Physician and Department Chair/Service Center Administrator, we have reviewed the above-named 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 DATE Name Printed DATE Alte nate Supervising Physician SigIlljture' L-"C.V\ Name Printed DATE Alternate Supervising Physician Signature Name Printed DATE Dept Chair or Svc Center Administrator Name Printed Page 4 of 4