DELINEATION OF PRIVILEGES UROLOGY

Transcription

1 KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES UROLOGY ADULT UROLOGY (patients >18yrs.) LEVEL I (CORE) PRIVILEGES Applicant must have completed an ACGME-Accredited Residency in Urology or its Equivalent Level 1 (core) privileges are those able to be performed after successful completion of an ACGME accredited residency program in that core specialty. The removal or restriction of these privileges would require further investigation as to the individual s overall ability to practice, but there is no need to delineate these privileges individually. History and Physical for Diagnosis and Treatment Admission and Discharge Privileges ABDOMEN Closure of Evisceration Drainage, Retroperitoneal Abscess Excision, Retroperitoneal Tumor/Cyst Exploratory Laparotomy Herniorrhaphy, Incisional ADRENAL Adrenalectomy, Unilateral or Bilateral BLADDER Anterior Pelvic Exenteration with Urinary Diversion Cystolithotomy Cystostomy, Open Closed; or Trochar Diverticulectomy Enterocystoplasty Excision Urachal Cyst or Tumor Partial Cystectomy Partial Cystectomy with Ureteroneocystostomy Radical Cystectomy with Ileal Conduit, Continent Urinary Diversion, or Neobladder Repair of Enterovesical Fistula Repair of Rupture Repair, Vesicovaginal Fistula (Abdominal, Vaginal) Simple Cystectomy Simple Cystectomy with Cutaneous Ureterostomy Simple Cystectomy with Ileal Conduit Vesical Neck Plasty Vesicostomy ENDOSCOPY Cystoscopy Cystoscopy + Cup Biopsy, Bladder Cystoscopy + Ureteral Catherization Cystoscopy and Fulguration Cystoscopy with Placement of Ureteral Stent Cystoscopy, Calibration and Dilation Stricture; Internal Urethrotomy; Litholapaxy; Removal Foreign Body; Extration Ureteral Calculus;Hydrodistention of Bladder TUR Prostate; Valves; Bladder Neck; Bladder Tumor EPIDIDYMIS AND SPERMATIC CORD Epididymectomy, Unilateral Epididymovasostomy, Unilateral, Bilateral Excision Spermatocele Ligation Internal Spermatic Vein Vasectomy Vasovasostomy KIDNEY Continent Urinary Diversion (separate procedure) Drainage Renal of Perirenal Abscess ESWL Harvest of Cadaver Kidneys Heminephrourecterectomy Ileal Conduit (separate procedure) Nephrectomy, Donor Nephrectomy, Partial Nephrectomy, Radical Nephrectomy, Simple, Unilateral; Bilateral Nephrolithotomy, Simple, Staghorn or Percutaneous Nephrostomy, Open or Percutaneous Nephroureterectomy Percutaneous Endopyeloplasty Pyeloplasty;with Symphysisotomy Renal Biopsy, Open Renal Cyst, Unroofing Replacement of Ureter with Bowel Sigmoid Conduit (separate procedure) LYMPHATIC Lymph Node Biopsy Lymphadenectomy, Pelvic, Inguinal or Ilioinguinal Lymphadenectomy, Retroperitoneal PENIS Amputation, Partial or Complete Circumcision Insertion Penile Prosthesis Repair Major Injury Revascularization Shunt, Cavernosum to Spongiosum,Open or Percutaneous

2 Urology Name: Page 8 ADULT LEVEL I (CORE) PRIVILEGES PROSTATE I & D Prostatic Abscess Needle Biopsy - Ultrasound Guidance Needle or Open Biopsy Percutaneous Insertion of Radioactive Materials Prostatectomy, Perineal, Simple or Radical Prostatectomy, Retropubic, Simple or Radical Prostatectomy, Suprapubic Transrectal Ultrasound of Prostate Transurethral Laser ablation of prostate Transurethral resection of prostate (TURP) SCROTUM Excision, Partial or Complete Hydrocelectomy Incise and Drain Abscess Repair Scrotum (Trauma) TESTIS Biopsy, Testis Excision Lesion of Testis Insertion Testicular Prosthesis Orchiectomy, Inguinal (Radical) Orchiectomy, Simple, Unilateral or Bilateral Orchiopexy, Unilateral or Bilateral Reduction oftorsion + Fixation (Bilateral) Repair Testis (Trauma) Vastomy for Vasogram URETER Cutaneous Pyelo or Ureterostomy, Unilateral or Bilateral Transureteroureterostomy Ureterolithotomy Ureterolysis Ureteronecystostomy, Unilateral or Bilateral ADULT LEVEL I (CORE) PRIVILEGES URETER (CON T) Ureteronecystostomy, with Bladder Flap Ureteroscopy Ureteroscopy with Calculus Removal, Biopsy or Fulguration Ureteroureterostomy URETHRA Anterior Hypospadias Repair (Magpi/Mathieu) Biopsy of Urethra Closure, Urethro-Vaginal or Rectal Fistula Correction of Chorde without Hypospadias Repair Diverticulectomy Excision of Urethral Prolapse Fistula Repair Incise and Drain Periurethral Abscess Major Urethroplasty Male Sling Procedure for Incontinence Meatoplasty Meatotomy Prosthesis For Incontinence Reconstruction for Incontinence (Young-Dees-Leadbetter) Repair of Epispadias Repair of Epispadias with Continence Procedure Repair of Urethral Injury Retropubic Urethropexy (Marshall-Marchetti; Burch) Sling procedure, transvaginal, tran-obturator, retropubic, or pubovaginal approach Total Complex Repair Transpubic Repair Membranous Stricture, Perineal Urethrectomy, (separate procedure) Urethroplasty for Anterior Stricture, One Stage or Staged Urethrostomy, Internal, External or Perineal Vaginal Urethropexy (Stamey; Raz; Gittes; Tanagho)

3 Urology Name: Page 3 PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. ADULT LEVEL II PRIVILEGES If proctorship is a pre-requisite, contact the Medical Staff Office for instructions & to obtain the required forms. You must be approved with proctoring PRIOR to performing the procedure within Kaleida. LASER SURGERY Requires completion of laser surgery training in ACGME residency program (provide verification letter from you program director) or 1.) completion of an approved laser surgery training program within 18 months including hands on training for each laser privilege requested (attach documentation), 2.) Supervision of applicant performing new laser surgery procedures may be required. Vesical Neck Contracture with YAG or KTP Urethral Stricture with YAG or KTP Ablation of condyloma of external genitalia with CO2, YAG or KTP. Penile Lesion with YAG Prostatectomy with YAG, KTP or INDIGO Urethral Stone with YAG or KTP (unless fragmentation of stone prevents obtaining specimen) Ablation Urethral Lesion with YAG or KTP Ablation Ureteral Lesion with YAG or KTP Ablation of Renal Pelvic Lesion with YAG or KTP Ablation of Bladder Lesion with YAG or KTP Ablation Bladder Tumor with YAG or KTP LAPAROSCOPIC PROCEDURES PURE (NO Hand Assist) Requires completion of a Pure Laparoscopic Surgery course which includes Hands On experience in Pure Laparoscopy (attach documentation) and proctored performance of at least two (2) Pure Laparoscopic surgical cases with a Laparscopically (Pure) credentialed Kaleida Health surgeon or Urologist in attendance (attach proctor form); OR Laparoscopic(Pure) surgery training in ACGME Accredited residency program (provide verification letter from Residency Program Director); OR unrestricted privileges to perform Laparoscopic (Pure) Surgery in a WNY Consortium Hospital (provide letter from facility). Adrenalectomy; Nephrectomy (simple or radical); Nephroadrenalectomy; Nephroureterectomy (simple or radical); Partial Nephrectomy; Renal Cyst Decortication or Excision; Partial Pyeloplasty Pelvic Lymphadenectomy; Retroperitoneal Abdominal Lymphadenectomy; Variocelectomy; Abdominal Bladder Suspension Abdominal Sacrocolpopexy HAND-ASSISTED LAPAROSCOPIC PROCEDURES Requires completion of Hand-Assisted Laparoscopic course which includes Hands On experience (attach documentation) and proctored performance of at least two (2) of the listed Hand-Assisted Laparoscopic Procedures performed with the assistance of a credentialed Kaleida Health laparoscopic (Pure or Hand-Assisted) surgeon in attendance (attach proctor form); OR Hand-Assisted Laparoscopic training in an ACGME Accredited residency program (provide verification letter from Residency Program Director) OR Unrestricted privileges to perform Hand-Assisted Laparoscopic Surgery in a WNY Consortium Hospital (provide letter from facility). Adrenalectomy; Nephrectomy (simple or radical); Nephroadrenalectomy; Nephroureterectomy (simple or radical); Partial Nephrectomy; Renal Cyst Decortication or Excision; Pyeloplasty Pelvic Lymphadenectomy; Retroperitoneal Abdominal Lymphadenectomy; Variocelectomy; Bladder Suspension Abdominal Sacrocolpopexy

4 Urology Name: Page 4 ADULT LEVEL II PRIVILEGES (CON T) INTERSTIM THERAPY Requires documentation of having received training during ACGME accredited urology residency OR (1) attending a Theory & Technique course on InterStim Therapy, observing 2 cases performed by an InterStim-credentialed physician; OR (2) completing the InterStim on-line educational program and successfully completing training with the InterStim simulator; OR (3) completing the InterStim on-line education program and observing chronic lead placement at an InterStim experience physician site. If either pathway (1) or pathway (2) or pathway (3) is selected, then the physician requesting privileges in InterStim Therapy must be proctored on his first case by an InterStim credentialed physician and the requesting physician s performance deemed satisfactory by the proctoring physician. InterStim Therapy PROSTATE BRACHYTHERAPY Requires completion of Prostate Brachytherapy course including hands on experience(attach documentation), and proctored performance at 3 Prostate Brachytherapy cases with credentialed and accredited surgeon in attendance (attach proctor form) OR Prostate Brachytherapy training in ACGME Accredited Residency Program in Urology. Prostate Brachytherapy privileges TRANSURETHRAL NEEDLE ABLATION OF PROSTATE (TUNA) Initial request requires completion of course in TUNA including Hands On experience (attach documentation) OR received training in Prostate TUNA during an ACGME Accredited Residency Program in Urology (provide verification letter from program director) TUNA privileges TRANSURETHRAL MICROWAVE THERMOTHERAPY OF PROSTATE (TUMT) Initial request requires completion of course in TUMT including Hands On experience (attach documentation) OR received training in TUMT during an ACGME Accredited Residency Program in Urology (provide verification letter from program director) TUMT privileges RECIPIENT RENAL TRANSPLANTATION Requires documentation of completion of an accredited fellowship in Renal/solid Organ Transplantations with documentation by Fellowship Director as to proficiency in Renal Transplantation. Recipient Renal Transplantation allograft or autograft RETROPERITONEAL COLPOPEXY WITH VAGINAL MESH FOR CYSTOCELE (ANTERIOR) REPAIR Must submit evidence of having completed a didactic course on the use of vaginal mesh insertion in Cystocele repair and mentoring by a surgeon credentialed in this procedure for five cases OR received training in this procedure during an ACGME Accredited Residency Program in Urology (provide verification letter from program director). Retroperitoneal Colpopexy with Vaginal Mesh for Cystocele (anterior) repair CONSCIOUS SEDATION (Adult/Pediatric) 1. Initial Request: Must have completed a Kaleida Health approved training course (documentation required) or training during ACGME Accredited Residency (verification letter from program director required.) 2. Maintenance of privilege: The course needs to be taken again every 4 years. 3. The course can be found at: Conscious Sedation ADULT LEVEL III PRIVILEGES If proctorship is a pre-requisite, contact the Medical Staff Office for instructions & to obtain the required forms. You must be approved with proctoring PRIOR to performing the procedure within Kaleida. CRYOTHERAPY OF THE PROSTATE Requires successful completion of a recognized course in Cryotherapy of the Prostate (attach documentation) and proctored performance of at least 2 Cryotherapy procedures under the supervision and mentorship of a Cryotherapy certified urologist (attach proctor form) or received training in Cryotherapy of the Prostate during an ACGME Accredited Residency Program in Urology (Provide Verification from Program Director Cryotherapy of the Prostate

5 Urology Name: Page 5 ROBOTIC PROCEDURES UROLOGY LEVEL I If proctorship is a pre-requisite, contact the Medical Staff Office for instructions & to obtain the required forms. You must be approved with proctoring PRIOR to performing the procedure within Kaleida. 1. Applicant must have unrestricted privileges for open and/or laparoscopic surgery procedures for which robot assisted surgeries/procedures will be performed AND must provide documentation of successful completion of an advanced didactic robotic course to include certification of completion of a robot-assisted animal laboratory course. Observation of a minimum of two (2) robotic cases and must complete five (5) *proctored cases with satisfactory outcomes; OR 2. Applicant must provide documentation of unrestricted robotic privileges at another hospital system, with satisfactory outcomes including a case log of the most recent 50 cases; OR 3. Applicant must provide documentation of successful completion of computer assisted surgical training in residency/fellowship including robotic surgery with a case log of 50 cases of all robotic surgery and must complete two (2) *proctored cases with satisfactory outcomes; AND 4. Applicant must have first ten (10) robotic cases retrospectively reviewed by the clinical service chief and/or designee regarding meeting the quality standards established by the clinical department. 5. Applicant must perform fifteen (15) robot assisted prostatectomies and five (5) robot assisted bladder surgeries each year with satisfactory results to maintain privilege. *To qualify to proctor robotic surgery, an applicant must also have completed a minimum of fifty (50) robotic surgery cases with satisfactory outcomes, and must agree to be present in the OR during the entire surgical procedure being proctored. Robotic Prostatectomy Surgery (Maintenance - 15 cases a year required) A pre- or pro- peritoneal inguinal hernia repair may be performed through the same incision. Robotic Bladder Repair in conjunction with Robotic Prostatectomy Surgery Independent Robotic Bladder Repair (Maintenance - 5 cases a year required. Can be met by Robotic Prostatectomy or in conjunction with Robotic Prostatectomy Repair.) Robotic removal of a urachal cyst

6 Urology Name: Page 6 ROBOTIC PROCEDURES UROLOGY LEVEL II 1. Applicant must have Robotic Level I privileges at Kaleida Health; AND 2. Applicant must have unrestricted Pure Laparoscopy or Hand-Assisted Laparoscopy privileges at Kaleida Health; AND 3. Applicant must satisfy one of the following: A. Provide documentation of unrestricted robotic privileges in the specific additional procedure(s) requested from another hospital system and a case log of the most recent 10 cases; OR B. Provide documentation of successful completion of training in during an ACGME residency/fellowship of the additional procedure(s) requested (provide verification letter from Residency Program Director) AND be proctored on two (2) cases of the requested procedure by a Urologist or Surgeon credentialed to perform the procedure(s) at Kaleida Health; OR C. If the applicant cannot meet the requested criteria listed in 3A or 3B above, then the applicant must be proctored in the specific procedure(s) requested for five (5) cases and achieve satisfactory outcomes. 4. Applicant must have privileges to perform the additional requested procedure(s) through an open operative approach at Kaleida Health. * To qualify as a proctor for Level II robotic procedures, the proctor applicant must also have successfully completed a minimum of at least three (3) Level II robotic cases with satisfactory outcomes for each procedure the proctor applicant has been requested to proctor, and must agree to be present in the OR during the entire surgical procedure being proctored. Robotic Ureteral Reimplantation Robotic Pyeloplasty Robotic Repair of a Vesicovaginal Fistula Robotic Cystotomy Repair Robotic Retroperitoneal Lymph Node Dissection Robotic Renal Decortication Robotic Adrenalectomy Robotic Radical/Total Nephrectomy Robotic Partial Nephrectomy Robotic Sacrocolpopexy Robotic Vasovasostomy

7 Urology Name: Page 7 ROBOTIC ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL OR EXTRACORPORAL ILEAL CONDUIT URINARY DIVERSION OR EXTRACORPORAL URINARY DIVERSION (MALE OR FEMALE). IN FEMALES A HYSTERECTOMY MAY BE PERFORMED AS PART OF THE CYSTECTOMY. Or ROBOTIC ASSISTED ANTERIOR PELVIC EXENTERATION WITH INTRACORPORAL OR EXTRACORPORAL ILEAL CONDUIT URINARY DIVERSION OR EXTRACORPORAL CONTINENT URINARY DIVERSION (FEMALE). A. Training Acquired during Urologic Residency or Fellowship 1. Must have Level I Robotic Assisted privileges at Kaleida Health. 2. Training acquired during Urologic Residency or Fellowship. The applicant must provide a letter attesting to the applicants competence in the procedure requested. The letter must be signed by the Residency or Fellowship Director/Chairperson and must specifically document competence in Robotic Assisted Radical Prostatectomy and Robotic Assisted Radical Cystectomy and be submitted by the applicant at the time he/she requests the privilege. B. Training NOT acquired during Urologic Residency or Fellowship 1. Applicant must have Robotic Level I privileges at Kaleida Health; AND 2. Applicant must have unrestricted Pure Laparoscopy or Hand-Assisted Laparoscopy privileges at Kaleida Health; AND 3. Applicant must satisfy one of the following: a) Provide documentation of unrestricted robotic privileges in Robotic Assisted Cystoprostatectomy (male) and/or Robotic Assisted Anterior Pelvic Exenteration (female) from another hospital system and a case log of the most recent 10 cases of Robotic Assisted Surgery; OR b) Proctored for 2 cases of Robotic Assisted Cystoprostatectomy (male) and/or Robotic Assisted Anterior Pelvic Exenteration (female) by a Urologic Surgeon credentialed to perform a Robotic Assisted Cystectomy at Kaleida Health; OR c) If the applicant cannot meet the requested criteria listed in 3a or 3b above, then the applicant must be proctored in the specific procedure(s) requested below for three (3) cases and achieve satisfactory outcomes. 4. Applicant must have privileges to perform the additional requested procedure(s) through an open operative approach at Kaleida Health. Robotic Assisted Radical Cystectomy (male) with intracorporal or extracorporal ileal conduit urinary diversion and/or continent urinary diversion. e: A pre- or pro- peritoneal inguinal hernia repair may be performed through the same incision. Robotic Assisted Anterior Pelvic Exenteration (female) with intracorporal or extracorporal ileal conduit urinary diversion and/or continent urinary diversion.

8 Urology Name: Page 8 PEDIATRIC UROLOGY LEVEL I (CORE) PRIVILEGES History and Physical for Diagnosis and Treatment Admission and Discharge Privileges ADRENAL Excision of cyst Exploration only: unilateral or bilateral BLADDER Cystolthotomy Cystostomy: punch or open Diverticulectomy Litholapaxy Operation for incontinence, stress (female)-abdominal or vaginal approach Operation for incontinence, stress (male) prosthesis or other Operation for total incontinence (female) vesical neck plasty with ureteroneocystostomy Repair of rupture DIAGNOSTIC PROCEDURES Cystogram Cystoscopy and/or panendoscopy, diagnostic Cystourethrogram, voiding or with Cine Ileal conduitogram Nephrostogram Nephrotomogram Pyelogram, intravenous Pyelogram, percutaneous Seminal vesiculogram Urethral catheterization: with pyelogram or with differential function Urethrogram, retrograde KIDNEY Biopsy: needle or open Drainage of abscess: perirenal or renal ESWL Excision or decortication of cyst Exploration Nephrolithotomy: simple or staghorn calculus Nephrostomy Nephroureterectomy Pyelolithotomy Pyelostomy Pyeloureteroplasty Symphysiotomy (horseshoe kidney): alone or with pyeloplasty MISCELLANEOUS Closure of evisceration Exploratory laparotomy Incisional hernia PENIS Amputation:partial, complete with perineal urethrostomy Biopsy Circumcision Construction, penis Dorsal slit Applies to children 18 months to 18 years of age (except for circumcision). Applicant must have completed an ACGME-Accredited Residency in Urology or its Equivalent Excision of tumor or cyst Repair (injury) PROSTATE Biopsy: needle or open Incision & drainage of abscess: endoscopic or perineal Prostatolithotomy: perineal, suprapubic Repair of recto-urethral fistula SCROTAL CONTENTS Epididymovasostomy Excision of lesion of cord: hydrocele or tumor Excision of skin lesion Excision, hydatid, torsion Excision, lesion of testis Hydrocelectomy (tunica vaginalis) Incision & drainage of abscess Ligation of spermatic veins (varicocele) Orchiectomy, unilateral, bilateral incl. cord Orchiopexy (scrotal) Reduction, torsion testicle+fixation(unilateral/bilateral) Repair of testis (injury) Spermatocelectomy Testis biopsy Vas ligation Vaso-vasostomy URETER Biopsy, endoscopic or open Manipulation of stone with or without removal) Ureteral repair; lysis, excision of ovarian vein, retrocaval ureter; ureteroneocystostomy: simple or with plastic narrowing; excision and anastomosis. Ureteroplasty; ureteroureterostomy, ipsilateral, contralateral; ureter-calyceal anastomosis; closure of fistula: Uretervaginal or ureter-intestinal Ureterolithotomy Ureteroscopy Ureteroscopy with Calculus Removal, Biopsy or Fulguration URETHRA Biopsy Diverticulectomy: male, female, urethrotomy, external, internal Drainage of periurethral abscess Drainage of urinary extravasation Excision of caruncle; Repair (injury) primary Excision,, partial, for stricture or carcinoma Meatomy: male or female Repair injured urethra membranes: perineal, primary; suprapubic, primary; secondary, plastic repair Repair, urethral stricture, 1st or 2nd stage Repair, urethrovaginal fistula Urethral diverticulectomy (female) Urethrectomy, total

9 Urology Name: Page 9 PEDIATRIC LEVEL II PRIVILEGES (a) For those in practice five years or more, a letter and five case experiences documented within the last five years is required (b) For those in practice five years or less, a letter from trainee s department chair and case list from residency is required (c) For those in practice five years or more without case experience, list five cases under supervision with a Urologist already credentialed at Kaleida Health for these procedures Hypospadias repair: distal-glandular - subglandular ages 12 to 18 months Orchiopexy, inguinal, ages 12 to 18 months Inguinal hernia, ages 12 to 18 months Inguinal hydrocoelectomy, ages 12 to 18 months Scrotal hydrcoelectomy, ages 12 to18 months Renal Transplantation, newborn to 18 yrs. PEDIATRIC LEVEL III PRIVILEGES Requires 1 year post-residency fellowship training in Pediatric Urology and membership or eligibility for Urologic Section Pediatrics and Society for Pediatric Urology (newborn to 18 yrs.) ADRENAL Adrenalectomy, bilateral Adrenalectomy or Partial Adrenalectomy: Cortical Tumor or pheochromocytoma BLADDER Cystotomy for tumor: excision, electrocoagulation or insertion of radioactive substance Bladder tumor: biopsy or endoscopy resection Cystectomy: partial, simple with ureteroneocystostomy. Complete simple with cutaneous ureterostomy, ileal conduit, urterosigmoidostomy, bladder substitution or rectal bladder. Radical, with cutaneous ureterostomy, ileal conduit, ureterosigmoidostomy or rectal bladder Cystoplasty: ileum, sigmoid or cecum Vesicostomy Repair of exstrophy Repair of fistula: vesicocutaneous, vesicovaginal, vesicosigmoid, vesicorectal, vesicovaginorectal KIDNEY Repair (Trauma) Renal vascular operation Dialysis, peritoneal, extracorporeal, establishment of arteriovenous shunt

10 Urology Name: Page 10 PEDIATRIC LEVEL III PRIVILEGES (CON T) PROSTATE Prostatectomy: transurethral, Cryosurgical, suprapubic, retropubic simple or radical, perineal, simple or radical URETHRA Hypospadias repair: proximal and midshaft Epidspadias repair: urethral construction, repair of epispadias with incontinence URETER Repair of ureterocele, meatotomy, endoscopic, open repair with ureteroneocystostomy Ureterotomy for tumor Ureterectomy: partial or complete Ureterostomy: in situ or cutaneous Ureter-enterostomy (alone): Sigmoid, ileal conduit, colon: conduit Rectal bladder with sigmoid pull-through Ureteral substitution: bladder flap or ileum MISCELLANEOUS Pelvic Exenteration (Male or Female) Biopsy of retroperitoneal tumor Excision of retroperitoneal tumor Retroperitoneal node dissection Lymphadenectomy, Pelvic, Inguinal/Ilioinguinal Lymphadenectomy, Retroperitoneal Laparoscopy without orchiopexy Laparoscopy with orichiopexy Abdominoplasty for Prune Belly Syndrome Orchiopexy, abdominal, single or two staged Gonadectomy Unilateral or Bilateral Oophorectomy Unilateral or Bilateral KEY *NOT GRANTED DUE TO: Provide Details Below **WITH FOLLOWING REQUIREMENTS Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define) DETAILS:

11 Urology Name: Page 11 National Practitioner Databank Disclaimer Statement: Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C et seq.) Signature of Applicant / Date I recommend approval of the procedures requested by the applicant: a) as requested b) as amended I have consulted with the Chief of Pediatric Surgery who recommends approval of the requested Level II/III privileges for Pediatric care in Urology. / Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS Urology 2/2016