requested

Clinical Privilef!es Update Form

Laurie Archbald-Pannone Department of Medicine

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 of experience):

Current Privileges not to be Renewed: *

~

f" "*,""'~~Y""'"'*

i*Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; lor. in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you Iwill be notified and receive a copy of the report to be filed with the National Practitioner Databank.

-DA-TE--~~.\~~~\\~1--------_~~ 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. Sincwhe date of the last appointment, we have reviewed applicable information from the following sources of quali1y and utilization data: .

ws: Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as

D 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 f lows:_____________

Dffi;a{q DATE

LIAISON SIGNATURE

Revised 3/1/1006

lJNlVERSITYClinical Privileges Update Form ~qrVIRGINIA

Laurie Archbald-Pannone Department ofMediclne IWJJI HF..ALTH SYSTEM

I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional traiuing necessary to perform new privileges requested. (Please inelude supporting documentation to verify competency):

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

Curreut Privileges not to be Renewed:'"

-------..... --«_..._----­

!*P~i~il~~s~ioi;euel~ed are not repo;·ted liS belng'volunia~lIy "';lbJqulshed uni'~ thiSl;doU:e\~hlieyoiiare unde,'lnvestlgatloiil' jOl', hi return for not conducting aa Investigation or proceeding, If privileges are to be reported Ill! voluntarily relillqulshed YOII wiD be notmed and receive a copy of the report to be filed with the Natiollal 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 iJldieators (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...J&lIows: C.:;::.r'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: _____________

DATE DI LIAISON SIGNATURE

DATE DEPARTMENT CHAIR SIGNATURE

Peggy Plews-Ogan. MD Division Chief/Quality Liaison Mitchell Rosner. MD Interim Department Chair