8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
UROLOGY SURGERY
I hereby request surgical privileges in the specialty of Urology as shown in this
form. I understand that privileges granted are subject to a bi-annual review
coinciding with reapplication for medical staff membership. I also understand
that application for additional or new procedures can be made at any time with
proper documentation.
Please indicate with an X in the appropriate bo! and by signature at the end of
this document the procedures you are requesting privileges for.
"pplied for "pproved
#ystourethroscopy with biopsy $%& '(
#ystourethroscopy with fulgeration $%& '(
#ystourethroscopy with dilation and bladder $%& '(
#ystourethroscopy with resection bladder tumor $%& '(
#ystourethroscopy with optical urethrotomy $%& '(
#ystourethroscopy with stent insertion $%& '(
#ystourethroscopy with stent removal $%& '(
#ystourethroscopy with ureteroscopy and)or pyeloscopy $%& '(
#ystourethroscopy with ureteroscopic lithotripsy $%& '(
*U+P $%& '(
,ithotripsy -%&.,/ $%& '(
0eatotomy $%& '(
%!cision urethral caruncle $%& '(
%!cision urethral prolapse $%& '(
1ypospadius repair with urethroplasty $%& '(
%!cision lesion testil $%& '(
(rchiectomy2 simple $%& '(
(rchiectomy2 readica-inguinal approach $%& '(
%!ploration undescended testicle $%& '(
+eduction tortion of testis $%& '(
(chiope!y $%& '(
1erniorrhaphy $%& '(
"33%3 45)46)54
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
&permatocelectomy $%& '(
1ydrocelectomy $%& '(
7asectomy $%& '(
Penile biopsy $%& '(
#ircumcision $%& '(
Penile prosthesis $%& '(
Prostate biopsy $%& '(
&uprapubic catheter insertion $%& '(
7asovasorrhaphy $%& '(
Radiography Use of Modality & interpretation of images
(therapeutic and diagnostic
$%& '(
Ultrasound Use of Modality & interpretation of images
(therapeutic and diagnostic
$%& '(
!luoroscopy Use of Modality "ith State License &
interpretation of images (therapeutic and diagnostic/
$%& '(
Local anesthesia $%& '(
#onscious Sedation $%& '(
Super$ision of #onscious Sedation %rained Registered
&urse
$%& '(
(*1%+& '(* ,I&*%3
$%& '(
$%& '(

$%& '(

Signature of Applicant Date

Signature of Medical Director [Jason Snibbe,MD] Date recommended
"33%3 45)46)54
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Signature of Managing Member [Kiarash Michel, MD] Date recommended
"33%3 45)46)54