AHP Clinical Privileges Update Form Lori Grove Department of Otolaryngology- Audiology 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): 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. I)/,IIJO/o Date I ( ft,_/-~) /~",<S'"./''-. f)/&l-~ Prac tioner's ~i natur f As the Supervising Physician/QI Liaison/Department Chair edi 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: ~ Medical Record Review ~ Continuing Education Conferences o Physical & Mental Health related to Job Performance o Risk Management Events/Quality Management Reports for claims o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ------------------------------------------------------------------------------------ ' ~ Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SCA We find as follows: III 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 r iew in months. Date 4 Tucker Gleason Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Printed Name Paul Levine, M.D., Chair Printed Name revised 3/1/2005

~/' Lori CroU-l... ---':~: have reviewed the privileges previously granted (copy attached) to me and reque 8ew 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 ~g As the Supervising PhysicianlQI LiaisonJDepartment Chair/Medfcal 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: Medical Record Review Continuing Education Conferences ~ Physical & Mental Health related to Job Performance (XJ Risk Management Events/Quality Management Reports for claims Annual Evaluation o Student Evaluation o Annual Review by Dept. Chair or SeA o Prescriptive Privileges (8 hours continuing education documentation required every 2 years) Other ------------------------------------------------------------------------------------ We find as follows:!p... 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 subj t to a review in months. 5 \~-ot3 Date Pri Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name 6jJ;- I Date Printed Name?/it{L A. &tvlrj~ f.l1} Printed Name ) revised 3/1/2005

AHP Clinical Privileges Update Form '=(JV"t' Gte ~ Department of {){P rcl~~ (ot~ -4d (( ~U ~ ave reviewed the privileges previously granted (copy attached) to me and reques e foi~ing changes:./ f~ew Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be renewed: * *Privileges not renewedare not reported asbeing voluntarily relinquished unlessthis is donewhile you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported asvoluntarily relinquished you will benotified and receivea copy of the report to be filed with the National Practitioner Databank. Date 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 qualitications are appropriate. Since the date of the last "'-'\oointment, we have reviewed applicable information from the following sources of quality and utilization data: ~ Medical Record Review ~ Continuing Education Conferences.\Xl Physical & Mental Health related to Job Performance ~ 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: Ii' 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 toa revi w in months. Date Printed Name Date Alternate Supervising Physician Signature Printed Name Date Altern-ate Supervising Physician Signature Printed Name Date Alternate Supervising Physician Signature Printed Name Printed Name f1'u L- 1/. i.bv 0';. ; Nb Printed Name revised 3/1/2005

Privilege List for: Audiologist 05-Jun-03. (1 Name: J)2~{;6 V1:...-ffl-!..-=...U _ Date: j(...:...!60--\-={ O~(p PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; ElYIERGENCY 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 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. D The applicant will manage patients as an independent audiology function. -<!enerj.i eneral Telephone Triage/Consultation Comprehensive Audiologic Evaluation Cranial Nerve Assessment Evoked Potential Testing Hearing Aid EvaluationlFitting and Follow-up Intraoperative Monitoring New Born Hearing Screening Tinnitus and Hyperacusis Evaluation and Management Vestibular and Balance Evaluation and Management Cochlear Implant Evaluation and Management Central auditory processing disorders - Evaluation and Man Cerumen Management Neonatal Ped Adol Adult Geriatric 'TI --:D 'D '/) 'D -n --V V -n 'D P./ -e; f:) 0 b '"'1) U 1) 'D D irh 'D J) 'D J) 07 {b 0 0 (6 'D.. f\- A- p- 1Jr. A f1-0 -V n F) T) Fr Pt: r+ ft OTHER PRIVILEGES Neonatal Ped Adol Adult Geriatric 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 practitioner's qualifications are appropriate. DATE Name Printed DATE ~ J---,-/-Iv{o_' _. Name Printed Name Printed.D.