CUDleal Privileges Update FOnD

Terry Overby Department of Medicine

IIaaYe reviewed tile privileges prevlo.....,. INDted to me aad request tile IoUowtlll _DPS to iDelude aay Dew tIaerapIes, praced....., or &ddtdoul traialDa a........, to perferm Dew prlvUea" ..... aested. (PIeaIe lDcIacle aappordDg docameatatiOD to verify eompeteaey):

New Privileges to .,. Added (please ladicate eatep17leve1aad type 01 uperleaee):

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ca.rnat PrlviIeps DOt to be BeDewed:*

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telf'," zf::~DAn CL:11JRE

AI tile DIYllIoD HeadIQl LIaison and Depa 'rlMedlcal Director, we ;"ve reviewed tile abov. named elfnldan'. level ofexperience, past performance and quality Indlcaton (If renewtna privileges) as related to requested privileges and ...that tile above named cllllklan', quaHfteadons are appropriate. SID']! tIae date of tIae last appoln....... we bave reviewed applicable Information from tile followlDllOUnes of quality and utilization data: .

We tInd as f~; t"

~ nMew with recommendation of reappoIntment to the cllnlcal8laff with ollnlcal ~_ 88 raqlated I. .~. . ,

D Concema not8d on review with cOlT8Ctlve action plan In place with recommendation of ....q,_ntment to the cllnlcal8laffwith privileges 88 raqueeted, but subject to a review In __months.

D Should have clinical prIvI..... granted but restricted 88 roUowa:.__________

\.'O\'~01 \2 . A./ . DATE DMS1~uAiSON SIGNATURE O'(.v..'i.",­

- __._~1i._.. __ ____ ~ d?i 14 r.~___ DAn DEPARTMINTCHAIRSlGNA11JRE 3) .... \\(\1"\

'"~.U lVERSITI'Clinical Privileges Update Form

•q~II~INIATerry Overby Department of Medte.lne HEALTli SYsTEM

I have reviewed th.e privileges previously granted to me and request the foUowing chanees to inelude any new therapies, proeedures, or additional training necessary to perform new privileges requested. (pleaH inelude supporting documentation to verifY competency):

New Privileges to be Added (please indicate category level and type ofexperienee):

Current Privileges not to be Ren~ed:*

._-------+_._--,,_..,-_.__..._------------ ­

---,...-----~f+-----.---.-.- ..--.

--.-------"-F------.-.....--..~,---.----------

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;P;i~J;g;·.;;~~m_'Rpoib:d"u·bti.·votPiariiynu;'.iiiW'iI;-"""-';·id~-Wiiik ';;·U;·"diriiiftlilitiOili·· or,ln retva for Dot eoDducdlll .alnvatlptloD or proeeediDg. Hprtrilegc. are to be reported .. YUI....rIJy rtII.qa..... , •• willie IIOtIfted alld mel" a eopy or tile report to be flied wlUl the Nat1eoaI Pntedlloltcr Ba.....k.

DATE

As the Division HeadlQl LlaisoD aDd Depa irlMedieal Director. we bave reviewed tile above­named cUolclao'slevel ofexperieoee, put pedOrDlaDte aad quality indicaton (if reDewiDg privileges) as related to requested privileges aad agree that tile above aamed eliDieian's qualfieations are appropriate. Sinee the date orlbe last appointment, we bave reviewed applicable JafenaatioD rro. tile folowJResources of quality and utilization data:

We~IS~··

~e review with AlCommendation of reappofntment to the clinical staffwith cIWcaI privileges .. requested

o Conceme noted on review with COf'I'8ctiYe action plan In place with recommendation of reappointment to the clinical staffwltb prIvllege8 -Nqueeted, buteubject to a nwiew in __monlhl.

o _uld_oli_~iJbut___foU DATI __ d_rJvIp Dl\'~'.G""'11JU DATE DEP CllAJRSlGNA11JRE

"ark Okusa. MD !ivision Chief/Quality Liaison

lIitchell Rosner! MD ,terim Department Chair

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