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2 Clinical Privileges Update Form I UNIVERSI'ITI <?TVIRGINIA Sugoto Mukherjee Department ofradiology ~. HF--ALTH &YSTE lvl 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:* ~ ,,~-.~-~ ""--..--,-,--.".---,,---,, ~.-,, ~-~--'--""---'----""---''' As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician1s 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. Sin. tbe date of the 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 montns. Should nave clinical privileges granted but restricted as foilows:, -----, ~~1f~ DEPARTMENT CHAIR SIGNATIJRE nevlml3l1l20g6

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14 " :~ r~-- Clinical Privileges Update Form Mukherjee Department of Radiology U~iWERsrrY ~qvirginia.health~ I have reviewed the privileges previously granted to me and request the following changes to include any newtherapies,procedures,or additional training necessary to perform new privileges requested, (PleaseInclude supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): CurrentPrivileges not to be Renewed: * *PrivilegesD.()t renewed ire notreported ~sbeili.gv(}luntarily relinquished unless this is done while you are under investigation; or.in return for,n()t condul:iillg all investigation or proceeding. If privileges are to be reported as voluntarily relinquished you,will be notified and receive a:copy:<,ftbe I:et)ort tobefiled with the National PractitionerDatabank, ".(i...jr V'/.dPIM~'<{{.c,-' _ CL~ICIAN.TURE " " I ' As thej~ivisioili-tead/~rpais()n a~l(id pattmentcbair!medicaldiredor,. wehave reviewed the abovenamed clinici~n'slevelofexperience, pastperfomllince and quality indicators (if renewing privileges) as related to requested,prwil gesand agree that the above named cltntclan'squaliflcationsare appropriate. Since the da~eofthe ~ast,app()intment, we have reviewed applicable information from the following sources of quality and utilization data: Wefmd as follows:, o Acc~pta'l:lle re"iew with recommendation of reappolntment to theelinlcal staff with clinical privileges as re,quested ' ' D Coryc;ernsno!edon review With correctivea,ction plan inpll;lce with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a reviewjn months. o 7f;/;O Should have' clinical privileges granted but restricted as follows:-:-- " "= :::fiy _D ~~~1J4tL-~'LP-ML-- Revised

15 Clinical Privileges Update Form Sugoto Mukherjee Department of Radiology I have reviewed the prlvlleges 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): Ch~ltP-ornfl,~kV New Privileges to be Added.tplease indicate category level and type of experience)':..$ialtts II fi-ndl'tt df!mjpatcj/ ~~ ~fy\ CL~ Current Privileges not to be Renewed:* ~, _A, *Privilcges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation;!.or, in return for not conducting an investlgatlon or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of rhe report to be filed with the National Practitioner Databank. ~ [ (hi 71J~g - -n-a-t-e---'-:f l CLINIC) SIGNATURE As the Division Head/QI Liaison and Department ChairlMedical 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 quality and utilization data: We find as D lows: 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. os;j;.;0;rivneg e. granledbulrestrictedas 10:'_,,. ~_.-r--r DATE 0dCl7/ O~ AlSON SlGNATU.lATE l{. Revised

16 U~lY~ERSITY illc?!_virginia. HEALTH SYsTE!vt L. -.J fir, {77 (J Narne REQUEST FOR CLINICAL PRIVILEGES Department of Radiology fi/ t J 1<J1 C",f ;IF.: t,'+ll[;7l'l NA-tioNk1- I1EDltAL {;LLI::-~,f l If19 Medical School and Year of Graduation C;, r<. tv] r-d' OrL C1JL..l- L,E # -::;A p. Vf i1 O F 111t16., Residency Training Location and Years Nl:lI/(fJ I~Jt'J)tow~ Y,- U 'VA (4. YC1#(5') I JUcy hv{, In -:run E 'h1j~ / Fellowship/Post-Residency Training Location and years _! NblJt) ~ (.JrY&/f(.~)!ir./j)IA) ~~~~~~~ ~I Board Certification in Year of Certification VIR.. FFLL:DWt'H/P / ClN/V.of Ltt.,JA (J4'~~~8i:'6) PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT ~ BLANK. According to category, enter A, B or C in the REQUESTED column. Category A The applicant will not undertake patient management except in emergency. Category B Category C The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties. The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally. Type 1 Type 2 Type 3 According to type, enter 1,2, or 3 in the EXPERIENCE Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training column. PRIVILEGES REQUESTED AREAS CATEGORY 'TYPE. REQUESTED c, EXPERIENCE.(A,Bore) (1,2:or3) ABDOMINAL RADIOLOGY Clinical consultation: differential diagnosis and treatment BREAST IMAGING Clinical consultation: differential diagnosis and CHEST RADIOLOGY Clinical consultation: differential diagnosis and NTERVENTIONAL RADIOLOGY Clinical consultation: differential diagnosis and II

17 "If MUSCULOSKELETAL NEURORADIOLOGY NUCLEAR MEDICINE Clinical consultation: differential diagnosis and Clinical consultation: differential diagnosis and Clinical consultation: differential diagnosis and c L PEDIATRIC RADIOLOGY Clinical consultation: differential diagnosis and II. PROCEDURES.... _- According to category, enter A, B! or C in the REQUESTED column. Category A Category B Tile applicant will not undertake the procedure except in emergency. Tlhe applicant will occasionally perform or assist in the performance of the procedure. sought in the event of anticipated or actual difficulties. Consultation will be Category C T e applicant will perform the procedure. occasionally. The applicant would be expected to request consultation only According to type, enter 1, 2, or 3 in the EXPERIENCE column. Type 1 Type 2 Type 3 Completed Formal Training Program Limited Experience - without formal training Extensive Experience - without formal training PRIVILEGESREQUESTED _ AREAS CATEGORY. TYPE REQUESTED EXPERIENCE i. ~',, (A,Bore) (1,2 or 3) ABDOMINAL!-_--L- RADIOLOGY Gastrointestinal Conscious sedation CT Cyst/abscess CT Cystography Fallopian tube recanalization Hysterosalpingography Intravenous urography MRI drainage Diagnostic contrast examinations Fine needle aspiration and biopsy Fluoroscopy Foreign body extraction Luminal stent insertion MRI Percutaneous tube placement Plain film radiography Stricture dilatation -_.._ _ _------_. Ultrasonography _ _ Genitourinary Antegrade urography Conscious sedation -L---..L.----.J

18 ABDOMINAL RADIOLOGY - cont'd BREAST IMAGING CHEST RADIOLOGY INTERVENTIONAL RADIOLOGY MUSCULOSKELETAL RADIOLOGY Genitourinary Percutaneous Plain film radiography Retrograde pyelography Retrograde urethrography Ultrasound interventional GU procedures._ Voiding cystourethroqraphy _.J.:: -. _ -. Obstetric/gynecological ultrasound _.._. Conscious sedation Fetal ultrasonography Transabdominal Transvaginal I 1 Conscious sedation _.._._--_ _---_.- _--_ _-_.. _.-.._--_......_...._-_ Galactography.._......_..._- _. _... _...._-_... _...._._ Mammography -Needie iocaiization _...,. _.... _. ;; _... _ Son o graph ica iiy gu id"e cffnterven iion a"i"p roceci"ures.. _.... _ ~~~~~.~~9..~!~~!.~.~~j.9..~9. ~.~.!:.~~~.!~~.~~~p:..~9.~9.ye:.~ _... Ultrasound. Conscious sedation CT Percutaneous biopsy _ _ Percutaneous drainage procedures _..._..._ Plain film radiography Arteriography _ _...._ Arthrography.. BaiiO o ii-pjacement...._.. _.._.. _...._ _.. _ _ Biliary drainage._ Conscious sedation _ _ _ Fallopian tube recanalization _ _ Intravascular foreign body removal... _...-- _..- _--- _._ _.._ -. Luminal stent placement..._...._-_ _..-._. _......_. Lymphography _ Percutaneous embolization _ Percutaneous interventional GI and biliary..._ _ Percutaneous nephrostomy stent placement _ _.. _...._ Percutaneous transluminal angioplasty... - _ _ _. Sialography... _.._ Vena cava filter placement Venography Conscious sedation CT Diagnostic and therapeutic soft tissue and osseous interventional procedures of: extremities, spine and its compartments, and all joints

19 MUSCULOSKELETAL RADIOLOGY - cont'd NEURORADIOLOGY Fluoroscopy _ _ -. MRI Osteodensitometry.._ _- _ Plain films _ _._00 Ultrasound NUCLEAR IMAGING PEDIATRIC RADIOLOGY Conscious sedation (same weight as radionuclide... ~~.~~!.~.~2.._.. _. _. Function studies/in vitro _ _..... _ therapy Radionuclide imaging -'Speci'ai"'lma'g'i'ng"(j'n'ciud'ing"'adre"n'ai"g'ian'ds'~antibo'dy"'"'''''''' -._. scans, bone marrow, cistemography, octreoscan,..p.~~~.~~~.~ ca~.i.!l..~~~..~..~ect) _.._. Sr-89 therapy Conscious sedation CT _ _._ _ _.. _. Diagnostic contrast examinations... ~ _ _. Doppler studies...._ Feeding tube placement _ _ Foreign body extraction _-_...._-_..._-_ _-_._...._--_.... MRI Percutaneous biopsy... _ _.- _-_. -.._.. _.... ~ _. Percutaneous drainage _.._...._. -._-_ _-_ Plain film studies and fluoroscopy..._ _-- _.. _ -...._ _. Stricture dilatation _ Ultrasound, DATE _~.J. _}{--:...-vlvt~_~lr---~u T CLINICIAN

20 < < -' P.age;;, \s Division Head/Ol Liaison and Department Chair, we have reviewed the above-named clinician's level of experience and past performance as related to requested privileges and agree the clinician's qualifications are appropriate. We have reviewed supporting documentation submitted for "other" privileges requested by the clinician and have, determined that documentation is adequate to verify competency. We find as follows: o Acceptable review with recommendation of appointment to the clinical staff with clinical privileges as requested. o Acceptable with proctoring as documented by the ~epartment Chair and/or Division Head/Ol Liaison. (v! ~""L/ ---T(o-A~~...\o; -~-- c3i/?!lor DATE 04/25/2007