8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
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PAIN MANAGEMENT
I hereby request privileges in the specialty of Anesthesia as shown on 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 marked by an asterisk !".
#he following privileges are requested and are consistent with my abilities$ training and experience.

Applied for Approved Denied
%eneral Anesthesia for
&ediatric "#S N$
Adult "#S N$
'ocal stand-by "#S N$
Intravenous regional block "#S N$
(egional Anesthesia "#S N$
'umbar epidural block "#S N$
Axillary block "#S N$
)audal block "#S N$
Interscalene block "#S N$
*locks of nerves of upper and lower extremities "#S N$
+tellate ganglion block "#S N$
,pidural *lock "#S N$
+pinal *lock "#S N$
*ier *lock "#S N$
Axillary nerve block "#S N$
#rigger &oint block "#S N$
-ccipital nerve block "#S N$
*)'+ "#S N$
A)'+ "#S N$
ADD,D ./0.10/.
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
I2 +edation "#S N$
3onitored Anesthesia )are "#S N$
IntraDiscal ,lectro#hermal #herapy ID,#" "#S N$
(adiography 4se of 3odality 5 interpretation of images therapeutic and
diagnostic"
"#S N$
4ltrasound 4se of 3odality 5 interpretation of images therapeutic and
diagnostic"
"#S N$
6luoroscopy 4se of 3odality with +tate 'icense 5 interpretation of images
therapeutic and diagnostic"
"#S N$
'ocal anesthesia "#S N$
)onscious +edation "#S N$
+upervision of )onscious +edation #rained (egistered 7urse "#S N$
Cervical interlaminar Epidurals "#S N$
Cervical transforaminal epidurals "#S N$
Cervical facet injections "#S N$
Cervical medial branch blocks "#S N$
Cervical medial branch radiofrequency ablation "#S N$
Thoracic interlaminar epidurals "#S N$
Thoracic facet injection "#S N$
Thoracic medial branch blocks "#S N$
Thoracic medial branch radiofrequency ablation "#S N$
Lumbar interlaminar Epidurals "#S N$
Lumbar transforaminal epidurals "#S N$
Lumbar facet injections "#S N$
Lumbar medial branch blocks "#S N$
Lumbar medial branch radiofrequency ablation "#S N$
Lumbar discograms "#S N$
Lumbar sympathetic plexus injections "#S N$
Intercostal nerve injection "#S N$
Thoracic outlet muscle injections "#S N$
ADD,D ./0.10/.
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Piriformis muscle injection "#S N$
Iliopsoas muscle injection "#S N$
acroiliac joint injections "#S N$
acroiliac joint radiofrequency ablation "#S N$
Caudal epidurals "#S N$
!ip joint injections "#S N$
"otulinum toxin injections "#S N$
pinal cord stimulator trials "#S N$
$thers n%t &isted' "#S N$
"#S N$
"#S N$
"#S N$
"#S N$
"#S N$
888888888888888888888888888888888888888888888 888888888888888888888
+ignature of Applicant Date

+ignature of 3edical Director 9:ason +nibbe$3D; Date recommended

+ignature of 3anaging 3ember 9<iarash 3ichel$ 3D; Date recommended
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