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«UNMH Ophthalmology Clinical Privileges Name: Effective Dates: From To _ All new applicants must meet the following requirements as approved by the ...»

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To the applicant: If you wish to exclude any procedures listed below, strike through then initial and date those procedures you do not wish to request.

1. Closed system vitrectomy, including peeling epiretinal or subretinal membranes

2. Laser for retinopathy of prematurity

3. Laser photocoagulation

4. Pneumatic retonopexy

5. Scleral buckle procedures Requested

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I have requested only those clinical privileges for which, by education, training, current experience, and demonstrated performance, I am qualified to perform and for which I wish to exercise at UNM Hospitals and clinics. I understand that: a) in exercising any clinical privileges granted I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation; b) any restriction on the clinical privileges granted to me is waived in an emergency situation, and in such situation my actions are governed by the applicable section of the medical staff bylaws or related documents.

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I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and recommend action and presently requested above.

Name:______________________ Signature_________________________ Date______________

Name:______________________ Signature_________________________ Date______________

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I have reviewed the requested clinical privileges and supporting documentation for the above-named

applicant and:

Recommend all requested privileges with the standard professional practice plan Recommend privileges with the standard professional practice plan and the conditions/ modifications noted below Do not recommend the clinical privileges noted below Explanation:________________________________________________________________________

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