DATE

DATE

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DEP

Revlltd MillO ...

.. ,f. ,'$(11,«2 . '~-Jf'I!!!=---+_~_. DIVISION ~ '/QI LIAISON SI NATURE

Clinical Privileges Update Form I UNIVERSITY1_<?fVfRGINIA Doris Haverstick Department of Pathology .tL l-!:EALTI-I ~YsTEM

I have reviewed the privUeges previoWlly granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new pl'ivileges requested. (Please include supporting documentation to verity 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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.prlviieg;;i~otre~ewe;J;I·t-~~trep;rted·a;·bei;g';;:;i~~t;;iiY;til;qUJShed';;~i;;Ssthi;i;'d;ile'';hue you'a;~'iinde~:'i;ivestig~tjoii'; "., or,ln retufll rOf not conducting an Invesilgation or proceeding. l!privileges are to be reported liS voluntarily relillquished you will be notified and receive a copy oft/Ie report to be flIuI with the Nattonal Practltloller Databank•

... :Z;-2?t.#~~?'-'_'_DATE I ) CLINICIAN SIGNATURE ----.

As the Division Head/Ql 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 of the last appointment. we have reviewed applicable informatIon from the following sources of quaJlty and Iltilization data: .

We ~s follows: Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested

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 .Unl.11 pri,,;legeo granted bulr.:.... "'OIIOW~III: ,

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