Clinical Privileges Update Form tJI).TIVERSITYqrVII{.GINIA

Reid' Adams DeparbnentofSurgery HEALTH SYsTEM

I have reviewed the privileges previously granted to me and request the following challges 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):

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Current Privileges not to be Renewed: *

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·Privlleges not renewed are not reported as beillg voluntarily relblqulshed ulIless thilis dODe while you are under Investigation; or, ID return for not conducting an Investigation or proceeding. Ifprivileges are to be reported as voluntarily relinquished you will be RotlRed and reeelve a copy of the report mbe ftled with the National PraetlClonel'Databank.

CUNICIAN SIGNATURE

As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the above­named clinician's level of experience, past perrormance and quality indicators (If renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Sinc~the date of the last appointment, we have reviewed applicable Information from the following sources of quatiiy and utilization data:

We find as follows: rl1 Acceptable review with recommendation of reappointment to the clinical staff with clinical prlvllegee as y-:" 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.

D Should have clinical privileges granted but restricted aS~fols:

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DATE DIVISION HEADIQI LIAISON SIGNATUllE

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