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I JJ),JLV f;' 1) S'l·rI·~Y !Clinical Privileges Update Form \ iJ'\ - ,L:">..", I

I"'IIIIIIII'''(~ 'VtRGJI'\JIA. I John Davison Regional Primary Care_UPG == HF..ALTH SYSTl~M I

I have reviewed the pr'ivileges previously granted to me and request the folJowing changes to include any new therapies, procedures, or additional training necessal'Y to perform new privileges requested. (Please include supporting documentation to verify compet~ncy):

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

Current Privileges not to be Renewed: '"

l*Privileges not reile~'I'ed a~:e IIOt reported as being voluntal'iiy,:elinqllished u,;less ti,isis dime while' YOll a~e llmler' h;vestigatloll;·· for, ill retllrn for not condlleting lin investigation or proeeeding. If privileges are to be l'eported as voluntarily relinqnished yOll lwill be notified and reeeive a copy of the repcl" to be filed with the Nationnl J'rllctitlollcr Databank.

As'the Division Head/QI Liaison and Department Chair/Medical Director, we 'have reviewed the above~ named 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 IS qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of qu;ity and util~zatlon data:

We find as ows: ,/

Acceptable review with recommendation of reappointment to the clinical staff with cllnlc.l privileges as I

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1'''-1 Concerns noted on review with corrective action plan in place with recommendation of reapP(i)lntment to the clinical staff with privileges as requested, but subject to a review In _ months. ' ­

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Clinical Privileges Update Form

John Davison Regional Primary Care

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 ofexperience):

Current Privileges not to be Renewed: *

------....... ..------~

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

......-~~-DATE CLINICIAN SIGNATURE

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. Since the date ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data:

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: _____________

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