8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
CARDIOLOGY
I hereby request surgical privileges in the specialty of Cardiology Surgery 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.
Documentation of training and experience is attached for those procedures mared
by an asteris !"# and those procedures that are outside of your original
specialty training.
$lease indicate with an %&' in the appropriate box and by signature at the end of
this document the procedures you are requesting privileges for.
(pplied for (pproved
CATEGORY I: Core Privileges of AMBULATORY SURGERY
C()DI*+*,-. /or-up 0 evaluation0 diagnosis0
consultation0 and1or provision of treatment to patients
presenting with cardiovascular disease or disorders and
related internal medicine disorders.
-2S 3*
CATEGORY II: SPECIAL CARDIOLOGY PROCEDURES
Special "rivile#es $hich ay re%uire additi&nal trainin#'e(perience)
NON-INVASIVE TESTING:
24, I352)$)25(5I*3 -2S 3*
2chocardiography Interpretation -2S 3*
3uclear Cardiac 5esting -2S 3*
,raded exercise stress testing -2S 3*
BASIC CARDIAC INTERVENTIONAL TESTING AND TREATMENT:
-2S 3*
Swan ,an6 Catheteri6ation -2S 3*
5ransesophageal echocardiography -2S 3*
2ndomyocardial biopsy -2S 3*
$ericardiocentesis

-2S 3*
$ercutaneous pericaridiotomy

-2S 3*
Cardiac Catheteri6ation -2S 3*
Coronary angiography


8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
5hrombolytic therapy -2S 3*
3on-selective aortic0 iliac and renal flushes associated
with cardiac catheteri6ation
-2S 3*
BASIC CARDIO-ELECTROPYSIOLOGY TESTING!TREATMENT:
Cardioversion- medical and electrical
5emporary pacer -2S 3*
$ermanent pacer -2S 3*
CATEGORY III: ADVANCED CARDIOLOGY PROCEDURES
Advanced "rivile#es $hich re%uire additi&nal d&cuentati&n &* trainin#'pr&*iciency
-2S 3*
ADVANCED CARDIAC INTERVENTIONAL PROCEDURES:
-2S 3*
Intra-aortic balloon pump placement -2S 3*
7alloon valvuloplasty -2S 3*
$ercutaneous 5ranscoronary angioplasty -2S 3*
Coronary stent placement -2S 3*
Coronary atherectomy -2S 3*
S5235I3,

()52)I(+ -2S 3*
C*)*3()- -2S 3*
C()*5ID -2S 3*
829*)(+
I+I(C -2S 3*
ADVANCED CARDIO-ELECTROPYSIOLOGY TESTING!TREATMENT:
-2S 3*
2lectrophysiology studies -2S 3*
)adiofrequency ablation -2S 3*
+ead extraction -2S 3*
ICD placement -2S 3*
CATEGORY IV: CRITICAL CARE PRIVILEGES
Special advanced critical care pr&cedures $hich $ill re%uire additi&nal d&cuentati&n &*
trainin#'recency &* e(perience +N,-. /0 1.23.S-/N4 0,1 .5.14.NC6 ,N768)
$atient 9anagement in the $(C: while awaiting (cute
5ransport to higher level of care
-2S 3*
(rterial cannula placement -2S 3*
2ndotracheal Intubation -2S 3*
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
C;$ line placement -2S 3*
;entilatory support management -2S 3*
Chest tube insertion -2S 3*
Cut down -2S 3*
OTERS NOT LISTED:
-2S 3*
-2S 3*
-2S 3*
-2S 3*
-2S 3*
-2S 3*
-2S 3*

Signature of Applicant Date

Signature of Medical Director [Jason Snibbe,MD] Date recommended

Signature of Managing Member [Kiarash Michel, MD] Date recommended