Dr Michael H Pfeiffer Threat Zambian Embassy Secret-Service Report -Washington, DC USA
Dr Michael H Pfeiffer- "Impostor Physician" DC Veterans Hospital - Neurology - In Germany Never...
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Transcript of Dr Michael H Pfeiffer- "Impostor Physician" DC Veterans Hospital - Neurology - In Germany Never...
DEPARTMENT OF VETERANS AFFAIRS Medical Center
50 Irving Street NW Washington DC 20422
June 3 2010
Mr Roy Morris Esq PO Box 100212 Arlington VA 22210
Dear Mr Morris
This letter is in response to your Freedom of Information Act (FOIA) request dated February 122010 received in my office on April 1 and referred to as 10shy05012-F You requested the following records from the Veterans Administration concerning the physicianresearcher Dr Michael H Pfeiffer who was recently hired at the neurological clinic at the Veterans Administration Hospital in Washington DC
1 The application of Dr Michael H Pfeiffer for employment at the VA Hospital
2 Any records regarding the hiring of Dr Michael H Pfeiffers at the VA Hospital
3 Records relating to Dr Michael H Pfeiffers position hire date compensation grade and responsibilities at the VA Hospital
4 Records relating to Dr Michael H Pfeiffers qualifications to practice as a physician at the VA Hospital including but not limited to his medical school transcripts
5 Records evidencing any medical license held by Dr Michael H Pfeiffer 6 Records relating to any of the pending complaints filed against Dr Michael
H Pfeiffer at the DC Board of Medicine andor the Virginia Board of Medicine
7 Records describing any studies experiments clinical trials or other research activities in which Dr Michael H Pfeiffer is or plans to be involved
8 Any engagements or contracts that Dr Michael H Pfeiffer might have with other government agencies including but not limited to any intelligence agencies
We have enclosed a copy of the requested records for items 2-4 Items 5-6 are of public record and can be viewed at the following websites httpdhp virginiagovmedicinel httpwwwdocboardorgdocfinderhtml We have no information regarding items 7-8
However we are withholding all information which if disclosed would constitute a clearly unwarranted invasion of an individuals personal privacy under FOIA Exemption 6 [5 USC sect 552 (b)(6)]
This request was processed by the undersigned You may appeal the determination made in this response to
General Counsel (024) Department of Veterans Affairs 810 Vermont Avenue NW Washington DC 20420
If you should choose to file an appeal please include a copy of this letter with your appeal and clearly indicate why you disagree with our determination
Enclosure
PFEIFFERMICHAEL H NEUROLOGY DUTY
LAST PP 10 POSITION INFORMATION
LABOR DIST CODE-1 COST CTRORG PAY PLAN OCCUPATION SERIES amp TITLE ASSIGNMENT FUNCTIONAL CODE
GRADE STEP SALARY PAY BASIS DUTY BASIS FLSA NORMAL HOURS POSITION NUMBER COMPETITIVE LEVEL SUPERVISORY LEVEL
Press RETURN to continue
82352223 NEUROLOGY a
060258 PHYSICIAN
15 01
9798700 1 1
000000 000
o
CLINICAL PRACTICE ANCILLARY MEDICAL
PER ANNUM FULL-TIME
STATION 688 TampL ~
PAGE 1
COUNSELING amp SERVICES
------------ -------------
- DEPARTMENT OF VETERANS AFFAI MEDICAL CENTER 50 Irving Street NW
Washington DC 20422
In Reply Refer To 688(llE)
VAMC 50 Irving Street NW Medical Staff Office 4C 1 05 Washington DC 20422
Attn Dr Michael Herbert Pfeiffer
This letter will serve to advise you of the disposition of your request for privileges or scope of practice at The Washington DC Veterans Affairs Medical Center in the Department of Neurology
_X__ Approved as requested (Copy attached)
Effective Date From 6172009 to 6162011
___ Approved with amendment(s) (Copy Attached)
Effective Date From to
Denied (See attached explanation)
Deferred (See attached explanation)
Ifyou have questions in reference to the information attached please contact the Medical StaffCredentialing office Rona Sebastian (202)745-8000 x 5257 Lewis Beasley (202)745-8000 x 5088 Brenda Talley-Smith (202) 745-8000 x 5530 or Felicia Shearin (202)745-8000 x 7853 Please remember that you may not work more than 2 years under your current privileges or scope of practice
Lewis C Beasley Program Specialist Medical Staff Office
___
Effective Date
VETERANS AFFAIRS MEDICAL CENTER WASHINGTON DC INITIAL CLINICAL PRIVILEGES APPLICATION
NAME----Lt--~(~---=(=l~l~e6_(--=f_-=--P_F_c_1-f_--fj_e_-rL--_____
Service I Specialty ____---L6lt_1_r__L_p-JI-middot-Jr-----------------shyCategory of~taff Membership
jltf Full-time staff I I Part-time staff I I woe I I Consultant I IOn-Station Fee Basis I IOn-Station Sharing Agreement I IOn-Station Contract
Request for Approval of Privileges
( request approval for the Clinica PriV~1 indic ted on the attached form
Signature of Applicant DateL--tlt--J 17 111th 1 SERVICE CHIEF
After careful review and consideration of the applicants credentials clinical competence information and health starus I
_---V Recommend Approval alii requellited
____ Recommend Approval with the roUowin~ deletions or modifications
____ Deletions _______________________
____ Modifications ______________________
EXECUTi COMMITTEE OF THE MEDICAL STAFF
___V__Recommend Approval of Service Chief Recommendation
____ Recommend Disapproval ofService Chief Recommendation (Use attachment for 1la~on)
Signarure (~n ~j~-Date~I1~Io-+-f_~Person y
ACTION BY APPROVING AUTHORITY
~pprove clinical privileges as reconunended by the Executive Committee of the Medical Staff
____ Disapprove clinical privileges as reconunended
-=6 -~ Signarure ____~__(____________ Date
Medical Center Director
Request for Privileges Neurology Service Washington VAMC
Namej1p~ d (ft r 6(pound ~ frpound I TTl IL Date P1If2PC 1
Subspecialty (if applicable)
f
C ( CItpound ~1-1 p -7Ji J It is assumed that all physicians in Neurology Service are requesting privileges in Neurology As such aU clinicians are assumed to be competent to do the following procedures in any setting
Insertion of nasogastric tube without wire Peripheral IV lines Intradermal injection ECG - perform Subcutaneous injection Suture removal
Urinary cather insertion (male amp female) Venopuncture
You may request privileges for the following procedures considered to be in the realm of Neurology Do not select your setting Your Section or Service Chief is responsible for selecting the setting of your approved privileges
Privilege
Arleri~1 puncture
Arthrocentesis
Paracentesis
Thoracentesis
Lumbar puncture x Skin biopsy
Sigmoidoscopy
ECG interpretation
EEG performance and Interpretation(including
Evoked (all)
)lt
Performance and Intrrrlgttlltitn
Care
inly~i~i bullcaQCj - e ~
~PliiClEiI Procedure (~g c~th lab
en~o fl4Jte)
EMG performance and interpretation
eep study Performanceinterpretation
Botox
Vagal other stimulator programming
Badofen Pump programming
Nerve Blocks
Jf)I ~~~~ ~~cJ - _ dr tiJ -
TOUBE For DomesticJU fRIORITYreg and International Use
1 COMPLETE ADDRESS LABEL AREA MIJIL Type orprint required return
UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
2 PA ___ meter strip to area I
o Unlfedst8tisPosra Setvrce- TO 1it 9ft -ttLampf~DEUllERYCOMRRMAtlOM- rd$J~)Jd2 ()bull Itampv t~~()f
label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
111111 J bullbullbull__bullbull
~
~ ~ It
~ I )
8 CI )
~ m ~ fh
We Delwar
However we are withholding all information which if disclosed would constitute a clearly unwarranted invasion of an individuals personal privacy under FOIA Exemption 6 [5 USC sect 552 (b)(6)]
This request was processed by the undersigned You may appeal the determination made in this response to
General Counsel (024) Department of Veterans Affairs 810 Vermont Avenue NW Washington DC 20420
If you should choose to file an appeal please include a copy of this letter with your appeal and clearly indicate why you disagree with our determination
Enclosure
PFEIFFERMICHAEL H NEUROLOGY DUTY
LAST PP 10 POSITION INFORMATION
LABOR DIST CODE-1 COST CTRORG PAY PLAN OCCUPATION SERIES amp TITLE ASSIGNMENT FUNCTIONAL CODE
GRADE STEP SALARY PAY BASIS DUTY BASIS FLSA NORMAL HOURS POSITION NUMBER COMPETITIVE LEVEL SUPERVISORY LEVEL
Press RETURN to continue
82352223 NEUROLOGY a
060258 PHYSICIAN
15 01
9798700 1 1
000000 000
o
CLINICAL PRACTICE ANCILLARY MEDICAL
PER ANNUM FULL-TIME
STATION 688 TampL ~
PAGE 1
COUNSELING amp SERVICES
------------ -------------
- DEPARTMENT OF VETERANS AFFAI MEDICAL CENTER 50 Irving Street NW
Washington DC 20422
In Reply Refer To 688(llE)
VAMC 50 Irving Street NW Medical Staff Office 4C 1 05 Washington DC 20422
Attn Dr Michael Herbert Pfeiffer
This letter will serve to advise you of the disposition of your request for privileges or scope of practice at The Washington DC Veterans Affairs Medical Center in the Department of Neurology
_X__ Approved as requested (Copy attached)
Effective Date From 6172009 to 6162011
___ Approved with amendment(s) (Copy Attached)
Effective Date From to
Denied (See attached explanation)
Deferred (See attached explanation)
Ifyou have questions in reference to the information attached please contact the Medical StaffCredentialing office Rona Sebastian (202)745-8000 x 5257 Lewis Beasley (202)745-8000 x 5088 Brenda Talley-Smith (202) 745-8000 x 5530 or Felicia Shearin (202)745-8000 x 7853 Please remember that you may not work more than 2 years under your current privileges or scope of practice
Lewis C Beasley Program Specialist Medical Staff Office
___
Effective Date
VETERANS AFFAIRS MEDICAL CENTER WASHINGTON DC INITIAL CLINICAL PRIVILEGES APPLICATION
NAME----Lt--~(~---=(=l~l~e6_(--=f_-=--P_F_c_1-f_--fj_e_-rL--_____
Service I Specialty ____---L6lt_1_r__L_p-JI-middot-Jr-----------------shyCategory of~taff Membership
jltf Full-time staff I I Part-time staff I I woe I I Consultant I IOn-Station Fee Basis I IOn-Station Sharing Agreement I IOn-Station Contract
Request for Approval of Privileges
( request approval for the Clinica PriV~1 indic ted on the attached form
Signature of Applicant DateL--tlt--J 17 111th 1 SERVICE CHIEF
After careful review and consideration of the applicants credentials clinical competence information and health starus I
_---V Recommend Approval alii requellited
____ Recommend Approval with the roUowin~ deletions or modifications
____ Deletions _______________________
____ Modifications ______________________
EXECUTi COMMITTEE OF THE MEDICAL STAFF
___V__Recommend Approval of Service Chief Recommendation
____ Recommend Disapproval ofService Chief Recommendation (Use attachment for 1la~on)
Signarure (~n ~j~-Date~I1~Io-+-f_~Person y
ACTION BY APPROVING AUTHORITY
~pprove clinical privileges as reconunended by the Executive Committee of the Medical Staff
____ Disapprove clinical privileges as reconunended
-=6 -~ Signarure ____~__(____________ Date
Medical Center Director
Request for Privileges Neurology Service Washington VAMC
Namej1p~ d (ft r 6(pound ~ frpound I TTl IL Date P1If2PC 1
Subspecialty (if applicable)
f
C ( CItpound ~1-1 p -7Ji J It is assumed that all physicians in Neurology Service are requesting privileges in Neurology As such aU clinicians are assumed to be competent to do the following procedures in any setting
Insertion of nasogastric tube without wire Peripheral IV lines Intradermal injection ECG - perform Subcutaneous injection Suture removal
Urinary cather insertion (male amp female) Venopuncture
You may request privileges for the following procedures considered to be in the realm of Neurology Do not select your setting Your Section or Service Chief is responsible for selecting the setting of your approved privileges
Privilege
Arleri~1 puncture
Arthrocentesis
Paracentesis
Thoracentesis
Lumbar puncture x Skin biopsy
Sigmoidoscopy
ECG interpretation
EEG performance and Interpretation(including
Evoked (all)
)lt
Performance and Intrrrlgttlltitn
Care
inly~i~i bullcaQCj - e ~
~PliiClEiI Procedure (~g c~th lab
en~o fl4Jte)
EMG performance and interpretation
eep study Performanceinterpretation
Botox
Vagal other stimulator programming
Badofen Pump programming
Nerve Blocks
Jf)I ~~~~ ~~cJ - _ dr tiJ -
TOUBE For DomesticJU fRIORITYreg and International Use
1 COMPLETE ADDRESS LABEL AREA MIJIL Type orprint required return
UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
2 PA ___ meter strip to area I
o Unlfedst8tisPosra Setvrce- TO 1it 9ft -ttLampf~DEUllERYCOMRRMAtlOM- rd$J~)Jd2 ()bull Itampv t~~()f
label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
111111 J bullbullbull__bullbull
~
~ ~ It
~ I )
8 CI )
~ m ~ fh
We Delwar
PFEIFFERMICHAEL H NEUROLOGY DUTY
LAST PP 10 POSITION INFORMATION
LABOR DIST CODE-1 COST CTRORG PAY PLAN OCCUPATION SERIES amp TITLE ASSIGNMENT FUNCTIONAL CODE
GRADE STEP SALARY PAY BASIS DUTY BASIS FLSA NORMAL HOURS POSITION NUMBER COMPETITIVE LEVEL SUPERVISORY LEVEL
Press RETURN to continue
82352223 NEUROLOGY a
060258 PHYSICIAN
15 01
9798700 1 1
000000 000
o
CLINICAL PRACTICE ANCILLARY MEDICAL
PER ANNUM FULL-TIME
STATION 688 TampL ~
PAGE 1
COUNSELING amp SERVICES
------------ -------------
- DEPARTMENT OF VETERANS AFFAI MEDICAL CENTER 50 Irving Street NW
Washington DC 20422
In Reply Refer To 688(llE)
VAMC 50 Irving Street NW Medical Staff Office 4C 1 05 Washington DC 20422
Attn Dr Michael Herbert Pfeiffer
This letter will serve to advise you of the disposition of your request for privileges or scope of practice at The Washington DC Veterans Affairs Medical Center in the Department of Neurology
_X__ Approved as requested (Copy attached)
Effective Date From 6172009 to 6162011
___ Approved with amendment(s) (Copy Attached)
Effective Date From to
Denied (See attached explanation)
Deferred (See attached explanation)
Ifyou have questions in reference to the information attached please contact the Medical StaffCredentialing office Rona Sebastian (202)745-8000 x 5257 Lewis Beasley (202)745-8000 x 5088 Brenda Talley-Smith (202) 745-8000 x 5530 or Felicia Shearin (202)745-8000 x 7853 Please remember that you may not work more than 2 years under your current privileges or scope of practice
Lewis C Beasley Program Specialist Medical Staff Office
___
Effective Date
VETERANS AFFAIRS MEDICAL CENTER WASHINGTON DC INITIAL CLINICAL PRIVILEGES APPLICATION
NAME----Lt--~(~---=(=l~l~e6_(--=f_-=--P_F_c_1-f_--fj_e_-rL--_____
Service I Specialty ____---L6lt_1_r__L_p-JI-middot-Jr-----------------shyCategory of~taff Membership
jltf Full-time staff I I Part-time staff I I woe I I Consultant I IOn-Station Fee Basis I IOn-Station Sharing Agreement I IOn-Station Contract
Request for Approval of Privileges
( request approval for the Clinica PriV~1 indic ted on the attached form
Signature of Applicant DateL--tlt--J 17 111th 1 SERVICE CHIEF
After careful review and consideration of the applicants credentials clinical competence information and health starus I
_---V Recommend Approval alii requellited
____ Recommend Approval with the roUowin~ deletions or modifications
____ Deletions _______________________
____ Modifications ______________________
EXECUTi COMMITTEE OF THE MEDICAL STAFF
___V__Recommend Approval of Service Chief Recommendation
____ Recommend Disapproval ofService Chief Recommendation (Use attachment for 1la~on)
Signarure (~n ~j~-Date~I1~Io-+-f_~Person y
ACTION BY APPROVING AUTHORITY
~pprove clinical privileges as reconunended by the Executive Committee of the Medical Staff
____ Disapprove clinical privileges as reconunended
-=6 -~ Signarure ____~__(____________ Date
Medical Center Director
Request for Privileges Neurology Service Washington VAMC
Namej1p~ d (ft r 6(pound ~ frpound I TTl IL Date P1If2PC 1
Subspecialty (if applicable)
f
C ( CItpound ~1-1 p -7Ji J It is assumed that all physicians in Neurology Service are requesting privileges in Neurology As such aU clinicians are assumed to be competent to do the following procedures in any setting
Insertion of nasogastric tube without wire Peripheral IV lines Intradermal injection ECG - perform Subcutaneous injection Suture removal
Urinary cather insertion (male amp female) Venopuncture
You may request privileges for the following procedures considered to be in the realm of Neurology Do not select your setting Your Section or Service Chief is responsible for selecting the setting of your approved privileges
Privilege
Arleri~1 puncture
Arthrocentesis
Paracentesis
Thoracentesis
Lumbar puncture x Skin biopsy
Sigmoidoscopy
ECG interpretation
EEG performance and Interpretation(including
Evoked (all)
)lt
Performance and Intrrrlgttlltitn
Care
inly~i~i bullcaQCj - e ~
~PliiClEiI Procedure (~g c~th lab
en~o fl4Jte)
EMG performance and interpretation
eep study Performanceinterpretation
Botox
Vagal other stimulator programming
Badofen Pump programming
Nerve Blocks
Jf)I ~~~~ ~~cJ - _ dr tiJ -
TOUBE For DomesticJU fRIORITYreg and International Use
1 COMPLETE ADDRESS LABEL AREA MIJIL Type orprint required return
UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
2 PA ___ meter strip to area I
o Unlfedst8tisPosra Setvrce- TO 1it 9ft -ttLampf~DEUllERYCOMRRMAtlOM- rd$J~)Jd2 ()bull Itampv t~~()f
label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
111111 J bullbullbull__bullbull
~
~ ~ It
~ I )
8 CI )
~ m ~ fh
We Delwar
------------ -------------
- DEPARTMENT OF VETERANS AFFAI MEDICAL CENTER 50 Irving Street NW
Washington DC 20422
In Reply Refer To 688(llE)
VAMC 50 Irving Street NW Medical Staff Office 4C 1 05 Washington DC 20422
Attn Dr Michael Herbert Pfeiffer
This letter will serve to advise you of the disposition of your request for privileges or scope of practice at The Washington DC Veterans Affairs Medical Center in the Department of Neurology
_X__ Approved as requested (Copy attached)
Effective Date From 6172009 to 6162011
___ Approved with amendment(s) (Copy Attached)
Effective Date From to
Denied (See attached explanation)
Deferred (See attached explanation)
Ifyou have questions in reference to the information attached please contact the Medical StaffCredentialing office Rona Sebastian (202)745-8000 x 5257 Lewis Beasley (202)745-8000 x 5088 Brenda Talley-Smith (202) 745-8000 x 5530 or Felicia Shearin (202)745-8000 x 7853 Please remember that you may not work more than 2 years under your current privileges or scope of practice
Lewis C Beasley Program Specialist Medical Staff Office
___
Effective Date
VETERANS AFFAIRS MEDICAL CENTER WASHINGTON DC INITIAL CLINICAL PRIVILEGES APPLICATION
NAME----Lt--~(~---=(=l~l~e6_(--=f_-=--P_F_c_1-f_--fj_e_-rL--_____
Service I Specialty ____---L6lt_1_r__L_p-JI-middot-Jr-----------------shyCategory of~taff Membership
jltf Full-time staff I I Part-time staff I I woe I I Consultant I IOn-Station Fee Basis I IOn-Station Sharing Agreement I IOn-Station Contract
Request for Approval of Privileges
( request approval for the Clinica PriV~1 indic ted on the attached form
Signature of Applicant DateL--tlt--J 17 111th 1 SERVICE CHIEF
After careful review and consideration of the applicants credentials clinical competence information and health starus I
_---V Recommend Approval alii requellited
____ Recommend Approval with the roUowin~ deletions or modifications
____ Deletions _______________________
____ Modifications ______________________
EXECUTi COMMITTEE OF THE MEDICAL STAFF
___V__Recommend Approval of Service Chief Recommendation
____ Recommend Disapproval ofService Chief Recommendation (Use attachment for 1la~on)
Signarure (~n ~j~-Date~I1~Io-+-f_~Person y
ACTION BY APPROVING AUTHORITY
~pprove clinical privileges as reconunended by the Executive Committee of the Medical Staff
____ Disapprove clinical privileges as reconunended
-=6 -~ Signarure ____~__(____________ Date
Medical Center Director
Request for Privileges Neurology Service Washington VAMC
Namej1p~ d (ft r 6(pound ~ frpound I TTl IL Date P1If2PC 1
Subspecialty (if applicable)
f
C ( CItpound ~1-1 p -7Ji J It is assumed that all physicians in Neurology Service are requesting privileges in Neurology As such aU clinicians are assumed to be competent to do the following procedures in any setting
Insertion of nasogastric tube without wire Peripheral IV lines Intradermal injection ECG - perform Subcutaneous injection Suture removal
Urinary cather insertion (male amp female) Venopuncture
You may request privileges for the following procedures considered to be in the realm of Neurology Do not select your setting Your Section or Service Chief is responsible for selecting the setting of your approved privileges
Privilege
Arleri~1 puncture
Arthrocentesis
Paracentesis
Thoracentesis
Lumbar puncture x Skin biopsy
Sigmoidoscopy
ECG interpretation
EEG performance and Interpretation(including
Evoked (all)
)lt
Performance and Intrrrlgttlltitn
Care
inly~i~i bullcaQCj - e ~
~PliiClEiI Procedure (~g c~th lab
en~o fl4Jte)
EMG performance and interpretation
eep study Performanceinterpretation
Botox
Vagal other stimulator programming
Badofen Pump programming
Nerve Blocks
Jf)I ~~~~ ~~cJ - _ dr tiJ -
TOUBE For DomesticJU fRIORITYreg and International Use
1 COMPLETE ADDRESS LABEL AREA MIJIL Type orprint required return
UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
2 PA ___ meter strip to area I
o Unlfedst8tisPosra Setvrce- TO 1it 9ft -ttLampf~DEUllERYCOMRRMAtlOM- rd$J~)Jd2 ()bull Itampv t~~()f
label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
111111 J bullbullbull__bullbull
~
~ ~ It
~ I )
8 CI )
~ m ~ fh
We Delwar
___
Effective Date
VETERANS AFFAIRS MEDICAL CENTER WASHINGTON DC INITIAL CLINICAL PRIVILEGES APPLICATION
NAME----Lt--~(~---=(=l~l~e6_(--=f_-=--P_F_c_1-f_--fj_e_-rL--_____
Service I Specialty ____---L6lt_1_r__L_p-JI-middot-Jr-----------------shyCategory of~taff Membership
jltf Full-time staff I I Part-time staff I I woe I I Consultant I IOn-Station Fee Basis I IOn-Station Sharing Agreement I IOn-Station Contract
Request for Approval of Privileges
( request approval for the Clinica PriV~1 indic ted on the attached form
Signature of Applicant DateL--tlt--J 17 111th 1 SERVICE CHIEF
After careful review and consideration of the applicants credentials clinical competence information and health starus I
_---V Recommend Approval alii requellited
____ Recommend Approval with the roUowin~ deletions or modifications
____ Deletions _______________________
____ Modifications ______________________
EXECUTi COMMITTEE OF THE MEDICAL STAFF
___V__Recommend Approval of Service Chief Recommendation
____ Recommend Disapproval ofService Chief Recommendation (Use attachment for 1la~on)
Signarure (~n ~j~-Date~I1~Io-+-f_~Person y
ACTION BY APPROVING AUTHORITY
~pprove clinical privileges as reconunended by the Executive Committee of the Medical Staff
____ Disapprove clinical privileges as reconunended
-=6 -~ Signarure ____~__(____________ Date
Medical Center Director
Request for Privileges Neurology Service Washington VAMC
Namej1p~ d (ft r 6(pound ~ frpound I TTl IL Date P1If2PC 1
Subspecialty (if applicable)
f
C ( CItpound ~1-1 p -7Ji J It is assumed that all physicians in Neurology Service are requesting privileges in Neurology As such aU clinicians are assumed to be competent to do the following procedures in any setting
Insertion of nasogastric tube without wire Peripheral IV lines Intradermal injection ECG - perform Subcutaneous injection Suture removal
Urinary cather insertion (male amp female) Venopuncture
You may request privileges for the following procedures considered to be in the realm of Neurology Do not select your setting Your Section or Service Chief is responsible for selecting the setting of your approved privileges
Privilege
Arleri~1 puncture
Arthrocentesis
Paracentesis
Thoracentesis
Lumbar puncture x Skin biopsy
Sigmoidoscopy
ECG interpretation
EEG performance and Interpretation(including
Evoked (all)
)lt
Performance and Intrrrlgttlltitn
Care
inly~i~i bullcaQCj - e ~
~PliiClEiI Procedure (~g c~th lab
en~o fl4Jte)
EMG performance and interpretation
eep study Performanceinterpretation
Botox
Vagal other stimulator programming
Badofen Pump programming
Nerve Blocks
Jf)I ~~~~ ~~cJ - _ dr tiJ -
TOUBE For DomesticJU fRIORITYreg and International Use
1 COMPLETE ADDRESS LABEL AREA MIJIL Type orprint required return
UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
2 PA ___ meter strip to area I
o Unlfedst8tisPosra Setvrce- TO 1it 9ft -ttLampf~DEUllERYCOMRRMAtlOM- rd$J~)Jd2 ()bull Itampv t~~()f
label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
111111 J bullbullbull__bullbull
~
~ ~ It
~ I )
8 CI )
~ m ~ fh
We Delwar
Request for Privileges Neurology Service Washington VAMC
Namej1p~ d (ft r 6(pound ~ frpound I TTl IL Date P1If2PC 1
Subspecialty (if applicable)
f
C ( CItpound ~1-1 p -7Ji J It is assumed that all physicians in Neurology Service are requesting privileges in Neurology As such aU clinicians are assumed to be competent to do the following procedures in any setting
Insertion of nasogastric tube without wire Peripheral IV lines Intradermal injection ECG - perform Subcutaneous injection Suture removal
Urinary cather insertion (male amp female) Venopuncture
You may request privileges for the following procedures considered to be in the realm of Neurology Do not select your setting Your Section or Service Chief is responsible for selecting the setting of your approved privileges
Privilege
Arleri~1 puncture
Arthrocentesis
Paracentesis
Thoracentesis
Lumbar puncture x Skin biopsy
Sigmoidoscopy
ECG interpretation
EEG performance and Interpretation(including
Evoked (all)
)lt
Performance and Intrrrlgttlltitn
Care
inly~i~i bullcaQCj - e ~
~PliiClEiI Procedure (~g c~th lab
en~o fl4Jte)
EMG performance and interpretation
eep study Performanceinterpretation
Botox
Vagal other stimulator programming
Badofen Pump programming
Nerve Blocks
Jf)I ~~~~ ~~cJ - _ dr tiJ -
TOUBE For DomesticJU fRIORITYreg and International Use
1 COMPLETE ADDRESS LABEL AREA MIJIL Type orprint required return
UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
2 PA ___ meter strip to area I
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label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
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UNITEDST4TES POST41SERVICEaddress andaddressee Information In customer block (White area) or on label (Ifprovided) Fromf~ ~h~
5dJllY~ ~ro-2tJf22- J1YMENTMETHOD
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label 228 JanuaIy 2008
PLACE LABEL HERE The efficient FLAT RATE ENVELOPE You dont have to weigh the envelopeJust pack all your correspondence and documents inside and pay only the FLAT RATE Priority Mail postage
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