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8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
NEUROSURGERY
I hereby request surgical privileges in the specialty of Neurosurgery 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
#arpal $unnel %ecompression& 'pen ()* N'
+#arpal $unnel %ecompression& )ndoscopic ()* N'
#arpal $unnel ,igament -elease ()* N'
+)ndoscopic %iscetomy ()* N'
)!tensor tendon repair& finger ()* N'
)!tensor tendon repair& hand ()* N'
.asciotomy with debridement ()* N'
.asciotomy& fle!or or e!tensor department ()* N'
.asciotomy& palmer for %upuytrens/s #ontracture ()* N'
0anglionectomy ()* N'
1icrodiscectomy ()* N'
Nerve -epair ()* N'
Neurolysis& ulnar ()* N'
Nec2 spine dis2 surgery ()* N'
-emoval of spinal laminal ()* N'
Radiography Use of Modality & interpretation of images
(therapeutic and diagnostic
()* N'
Ultrasound Use of Modality & interpretation of images
(therapeutic and diagnostic
()* N'
!luoroscopy Use of Modality "ith State #icense &
interpretation of images (therapeutic and diagnostic3
()* N'
#ocal anesthesia ()* N'
$onscious Sedation ()* N'
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Super%ision of $onscious Sedation &rained Registered
Nurse
()* N'
'$4)-* N'$ ,I*$)%
()* N'
()* N'
()* N'
+-equired Previous )!perience5 "pplicant should be able to demonstrate that
he6she has satisfactorily performed at lest three endoscopic discectomies during
the past three years.

Signature of Applicant Date

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

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