8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
COLON & RECTAL SURGERY
I hereby request surgical privileges in the specialty of Colon & Rectal 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.
ocumentation of training and e!perience is attached for those procedures mar"ed
by an asteris" #$% and those procedures that are outside of your original
specialty training.
&lease indicate with an '() in the appropriate bo! and by signature at the end of
this document the procedures you are requesting privileges for.
*pplied for *pproved
MINOR
+emorrhoidectomy ,-S ./
-!cision of *nal 0lcer ,-S ./
Incision and drainage of rectal abscess ,-S ./
1istulectomy ,-S ./
Rectal muscle biopsy ,-S ./
Repair of recto-vaginal fistula ,-S ./
*nal sphinctor repair for fecal incontinence ,-S ./
-!cision and fulguration of condyloma accuminata ,-S ./
-!cision or biopsy of rectal lesion ,-S ./
Removal of rectal foreign body ,-S ./
Cyro-surgery of rectal lesions ,-S ./
MAJOR
1iber-optic colonoscopy with or without biopsy or
&olypectomy
,-S ./
&olypectomy2 trans-rectal or trans-sigmoidoscopic ,-S ./
ENDOSCOPY
0pper 3I -ndoscopy ,-S ./
Colonoscopy ,-S ./
Colonoscopy with biopsy ,-S ./
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
*LASER
$.d4,*3 laser ,-S ./
C/
5
laser ,-S ./
+emorrhoidectomy ,-S ./
*rgon-6rypton laser ,-S ./
Radiography Us o! Moda"i#y & i$#rpr#a#io$ o! i%ags
&#hrap'#i( a$d diag$os#i()
,-S ./
U"#raso'$d Us o! Moda"i#y & i$#rpr#a#io$ o! i%ags
&#hrap'#i( a$d diag$os#i()
,-S ./
*"'oros(opy Us o! Moda"i#y +i#h S#a# Li($s &
i$#rpr#a#io$ o! i%ags &#hrap'#i( a$d diag$os#i(%
,-S ./
Lo(a" a$s#hsia ,-S ./
Co$s(io's Sda#io$ ,-S ./
S'pr,isio$ o! Co$s(io's Sda#io$ Trai$d Rgis#rd
N'rs
,-S ./
/7+-RS ./7 8IS7-
,-S ./
,-S ./
,-S ./

Signature of Applicant Date

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

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