BRADLEY MEMORIAL HOSPITAL And Health Center, Inc.
-- Clarence J. Silvia President and CEO
March 14,2006
USNRC REGION I 475 ALLENDALE RD. KING OF PRUSSIA, PA. 19406
PLEASE AMEND OUR BYPRODUCT MATERIALS LICENSE NUMBER 06-17145-01 AS FOLLOWS:
PLEASE ADD KENNETH K. HINES, M.D. AS AN AUTHORIZED USER FOR MATERIALS LISTED IN 10CFR.300. DR HINES HAS BEEN PREVIOUSLY AUTHORIZED ON STATE OF FLORIDA RADIOACTIVE
DELAND 701 WEST PLYMOUTH AVENUE DELAND, FLORIDA 32720. MATERIALS LICENSE NUMBER 2529-1 AT FLORIDA HOSPITAL
ENCLOSED PLEASE FIND A COPY OF THE SUPPORTING DOCUMENTS.
THANK YOU FOR YOUR CONSIDERATION.
PRESIDENT BRADLEY MEMORIAL HOSPITAL
81 Meriden Avenue, Southington, Connecticut 06489 860-276-5000
11/04/2005 FRI 9:OO FAX 386 943 3697 FL HOSP DELAND RAbOLOGY ~ o o 2 / 0 0 2 t
RAD I OACTIVE MATERIALS LICENSE SUPPLEMENTAL SHEET
MEMORIAL HOSPITAL - WEST VOLUSIA, INC. dlbla Florida Hospital DeLand 701 West Plymouth Avenue DeLand, FL 32720
ived April 20, 2005, State of Florida
12? A. T
William E Holler, M.D.
phosphorous 32, and iodine 131 for the treatment of thyroid carcinoma)
0
5D DD no
- - _________ -
OCT-26-2005 15:36 OPEN MRI OF GLASTONBURY 860 657 2264 P.03/15 ‘ .
Breast biopsy th& N,&
Slrnpla h radlcal mastectomy Thoracentesis & closed drainage Rib resect. for empyema Thorocoplsst y Intrathoracic surgsry Surwry of diaphragm Paraamterls Closure perforated ulcer Other gsstric surwry Remstedt Gatibleddsr L cbrnrnon duct surQev Splenectomy Pdmdsetic surgery Smali and larga bowel suraey APpsn-Omv AMomlnoperlneal resect. AWorninal explorat. after Harkup I &D of Intra-abdominal abscesses Traumaric lapdroramy Slrnple inguinal hernia Strangulared or recurrent hernia Ventral or Ismoral hernia Pilonidal cyst Hemorrhoid, exrernal hamorthoids. intsmal FlstWe in ano Hand infections 6najorl Hand lnfecrionr {minor)
- DELINEATION OF SURGICAL PRIVILEGES DESlRED
YES NO
n o o n 0 0 n u a n 0 0 n u U C I
n o 0 0
n u
F!: O D
n‘ 0 0 o n 0 0 a 0
O D
DELI NEATION OF GYNE. COLOGICAL Pfl) VI LEGES DESIRED
EAR SURGERY a Mastoldeccomy 0 0 Myringotomy
NASAL SURGERY 0 Polyps
El El 9p.m c7 u I IOCnJUTE5
THROAT SURGERY 0 Tonslls 0 0 Trecheotomy
GENERAL SURGERY Skin tumors spllt thicknesr grafts Wolff grafts Pedicle grafrs Skin lacerations Extansive burns Perotid gland surgery Lip and tongue surgery Ranula Epulis Resection of jaw Thyroglosriel ducts Branchial clefts Pharyngoabaph. dlvenlc. Thyroidectomy r’llienic nerm
U 0 0 0 0 0 0 a
J 3 7 7 3 z1 zl 7 3 L! Lulvsctomy - radial with
3 0 Vulveciomy - radlcal with groln dissenion
groln dlS8eCtlOn & hypagastrlc nodes
7 a Hysteretlomy, vaginal L] 0 Schaura Operation
D & C - diagnostic I & D - Banholin duct atscess Bartholin ducC Cysrectomv Biopsy of vulva Biopsy of cervix Conization of cervix - cold knife Conization of cervix - hot knife Perineotomy Pcrineorraphy Repair of rectocele Repair of enterocele ReDalr of cyslourethmcela Excision of Skenes duct cyst Excision of ursthral caruncle Vulvectomy - simple
. .. I
NEU~OLOGICAL S U A ~ E R Y Skullkracturss Cranibtomy Laminectomv
Hysterecto y, abdominal with or without
subtotal r adnexae total
Uterine suspension Presacral neunctorny Marahall-Marchettl Pubbveslcourethral susu. Radium insertion, cervix (Ernsr) Radium insertion, uterus (Heymans) Hysterectomy, radical, Wsrthsim Exenteration, complete Exenteration, enterlor Exenteration, posterior Selpinwctorny Ooptiorectorny Hyponastrlc aa. ligation Appendectomy Hymenotomy incompetent 06 surgery Repalr surplcal rent of Madder, b w e l Ureteral repair
I
YES NO 1 7 0 0 0 D C I f l u
0 0 0
0
Scalenorom Lumbar Syrnp. Tharacolumb. eymp. Intervertebral d i s h
VASCULAR SURGERY Vein Malor I l g r . vascular & :vipplng surgery
Arterial grafts
UROLOGICAL SURGERY
Pyelotomy Ureterotomy Cystostomy Suprapubic prosT8tlC rbSoct. Other suprepubic bladder su rg. Cvstectomy Cystomzopy & retrograde pyelogram Transurethral WRO. & omstate surgery Hydrocote, spermatmla, varicocele Vasectomy Testicular surgery Circumcision & meatotomy Major surQery of penis
Naphmctomy
i l
Uretaral transplant lncirional hernia fepalr Fundectomy Salpingxromy Skin graf-rlng Urethral caruncle- fulguretion Umbilical hernia repair L a F ~ r t b vaginal tepair Manchester-Fothergill opsration Repalrl rectovaginal f ish la Rspairlvesicovaglnal fistula Sturrndorf repair of cervix ~stsroaalplngograrn
Meckel’s diverfjcuiurn Hymnectomy Wedge reaection of ovaries . Hydetid mole evscuation Salpingoplasty Tubal lmplantation into merus Closure of vaginal ti:xula Evacuation of pelvlc abaceasas
OCT-26-2005 15:36 OPEN M R I OF GLASTONBURY
I l
c1 7
8613 657 2264 P.04/15
DE L1 NEATION OF GYNE- COLOG ICAL PR IVlLfGES OESlREO Conrinued)
DELINEATION OF OBSTETRlCAL PRIVILEGES DESIRED
DE LINEATION OF
'DIATRIC IVI LEGES
OESI R ED
YES NO
0 Evisceration repair '7 i':iiracromy
0 u ~wary inser t ion 0 0 ~ ~ a s r i c consxruction of
vagina with skin g a f t for congenital absence
YES NO
0 0 U U 0 Q 0 0 D
0 [7 rl
3 3 7 7 I1 J 3 3 7 7 7 7 Il 7 7 7
Spont. delivery, vertex presantation
emergency nonrrnsrgoncy
Eplaiotorny & repsir Breech Delivery Multipara Primigravida Frank
Fmtllng Mulclple pregnancy Low forceps - occiput anterior Mid forceps delivery Pre-eclampaia
Mild Moderate Severe
Eclampsia Cawrean suction
classical low cervical
Vmion 81 extraction Manuel removal of placenw Diihrssen's lnclslona Repalr of cervlcal laceratlons Cesareen hysterectomy Ceeaman Werthelrn Hypogastric aa. llgatlon Ectopic pregnancy - salpingectomy
IS
7 1 3 9 3 1 1 1 1
1
I J 3 I I 1
O
MINOR SURQICAL PROCEDURES I & 0 abscess Circumcision MeatatOmy Spinal rap Cur down Subdural tap Thoracsntesis Paracenresis Pericsrdiocentesit
MAJOR SURGICAL PROCEDUERS See Surgical Prlvileger Postopeative Cam
MEDICAL PEDIATRIC CARE Uncompliared Infections of:
respiratory tract gastrointestinal rract genitourinary skin wrlpherat nervous 6ysem
Compllcared infections of =me Fever of undetermined origin CsntraI nervous system in factions
YES NO
0 0 ~~pororny-exp~ora~ory 0 Trachelaclomy CI 0 Perineoplasty 0 0 Removal of foreign body
o a from vaglna & utarus
YES NO
0
0 0 n 17 0 0 0
0
0 0
0 0 U 0 c7 0 3
a
0
0
0 0 0 13
13 a c7 0 0
0 U 0
0
Tre+rnenr of medical comp liat ons of obstetrics- hear 1 , lung, kidney. snarkia, diabetes, eye. Plpei forceps application to altegornlng head Extraperitoneal Cesarean sedan Repair of uterine laceration! Repair of vaginal Jacerarlonr Abdominal pragnsncy Destructive operations - fetus craniotomy, besiotrips dacapitation, cranial punc. cur& cranioctasis, cleidorom' Colpocenresls Colpotomy CUI dovco py Arnniotomy Emergency Caserean SeCtlOn for hemorrhage Anesthesia - Dudendal block, local.
Evaduetron of vulv8r hems- tombra Circurncloion of infanr Repalr of 3rd & 4th degree lacerations
CARD1 OVASCU LAR Hyoertension Congenital heart disease Rhcumaric hem disease subacute bscterial endo, carditis Managemem of fallure Czfdisc regulators
ALeERGlC DISORDERS
Codplicated asthma
Uncpmpllated I asthma
Sedm sickness
ENDOCRINE METABOLIC DISORDERS Diabetes. uncempliceted Diabstes in were acidosis Diseases of Thymid Diseases of adrenal gland
DISTBUBANCE OF WATER ELECTROLYTE BALANCE
mild moderare savere
YES NO
0 0
a 0 u a n o
D O
YES NO 0
U 0 rl c3 n 0
iJ 0 U
a 0
Excision of vulvar lesions ar delivery Excision of vaginal cyrts Uterine packing Curatrage Aborrlon Postpanurn Rmuscitarion of infant Cervical biopsy durlng pregnancy - alw conization of cervlx Repall of Incompetent internal cervlcal os-cwclage, etc. Inversion of uterus Hemorrhoid excision Amniocenresla Management of fetal death in utero-lntre-arnniotic injec- tion o f hypertonic solutions Induction of labor -
medical surgical
0 0 a 0
7 7 3 z1 3
3 3 7 7 7
1
1 3 1
CI a
0 0 I7 0 0
0
0. U 0
0
YES NO
DISEASES OF BLOOD & BLOOD*fORMING ORGANS Leukemia Aplastic anemia Hemolytic anemia Hemophilia Jron deficiency anemia raquiring transfusion
MISCELLANEOUS Lipodystrophies Collagen diseases Nephritis & nephrosis Emtiondf disorders Distrubences of growth & devel Oprnent Sreroid therapy over 1 week duration
NURSERY PRIVILEGES Rourine newborn care Circumcision Clip ftenulum
PREMATURE INFANT CARE Without complication - over 4 Ibs.
OCT-26-2005 15:37 OPEN M R I OF GLRSTONBURY
FULL TERM INFANT CAR WITH COMPC(CATI0NS
0 0 Life threatening; surgicel 0 Life threatening; medical
0 0 Non-life Ihraataning: surgicd 0 a Non-life threatening: medla
3 YES NO
0 condylar
0 0 Dittocations 0 r] Fracture dislocations
Forearm Borh bone
Elbow
a Displaced 0 0 UnGisplaced
~
860 657 2264 P.0545
METACARPALS AND PHALANGES
Displaced U n displaced
Displaced Und ispleced
Avulsion fraetures Cornplicatbd Uncompi i a t e d
Lonsr extremity Femur
Singuler
Multiple
Dislowtion of hip Fracturedislocation of hlp Neck of femur I ntertcochmtet it Sublrochanterlc
edults Chi1 dresn
Sh(eft
Knee dlstal femur and
proximal tibia I Condylar fractures of femur Patelltrr dislocations Patellar dislocation with
' DELINEATION OF PEDIATRIC PRIVILEGES DESIRED Continued)
0 El 0
0 U 5
El f 3
0 0 0 0 0 0
a 3 7 3 3 0
DE L1 NEATION I YES NO
YES NO
0 Wi'lhout cornplicatibns - under 4 Ita.
PREMATURE JNFANT C A WITH COMPLI CAT1 ONS
0 0 Fife Threatening: surgical 0 a L i f e threetening: medical c1 13 Non-lite thrsarening; rurgin 0 Nan-life threatenins! media
OF ORTHOPEDIC PRIVILEGES DESIRED
OPEN FRACTURES Icomp.
t isue disruption c] 0 Fractures - minimal soft
0 0 Fractures - marked soft
D 0 0 0 0 0 cl J L l 0 7 3 3 7 7
3 7
I 1 1
1 I I
I I
0 0 a
0 0 0 17 0
' i L.-.
risrue disruprion
CLOSED FRACTURES (not Compound) Faclal bone
Maxillary Zyprnatic arch Orbits Man dl bles
Nasal banes D i sp lacsd Undisplaced
Linear Deprassea
S kul I
Spine Cervical Dorsal Lumbar
Displaced Undisplacad
Multiple Single
Pelulr
Ribs
UPPER EXTREMITY (FRACTURES & DISLOCATIONSJ
Clavicle . Displaced Undisplsced
Displaced Undisplaeed Dislocerlon scromlo- clavicular ioint
Dislocation of shouldar Anterior Poster io r Fracfure - dislocetlon of shoulder
Impacted Dfsplaced
Tuberoslrier Sepreted Unseparated
Surgical neck I rnpected Displaced
Displaced Undisp\aced supracondylar
C:apula
Anarornical neck
Shaft
A
YES NO
Single bone Oisplaced Undlsplaced
Collea' fracture Mlld defonnlty Moderate deformlty Severe deformlty Reverse Colles' [Smlth)
Carpal bones Wavlcufar Tranmarpal dislocations Carpel dislocdlims
fracture Patellar fracture6 Dlspleced Undisplaced Plateau fractures
Tiblal shaft Oisplaced Undispleced
fibular 6heft Oisplawd Undispleced
YES NO
E RY THROBLmOSIS a 0 Mild 0 0 Severe 0 [3 Reauirhg exchang
O D
D O o n
YES NO
o n n u n u n o n o o n O U
0 0 o n
Both bone Displaced Undispleced
Dislocation Fracture dislocation poll's -blrnalleolar Displaced Undisplaced
Ldreral malleolus Displaced Undisplaced
wedral ~ T W ~ O ~ I J S
ulspiacea
AnWe
Undiaplacad Avulsion fracturar of ankle
TARSUS GROUP 'Talus
Displeced thdirplscad
OiSplbcsd Undirplsced
Displaced Undisplecad Subestregslsr dislocations
calcaneus (os calcls)
Navicular
METATARSALS AND PHALANdES Singular
Displaced . Undiqlaced Multiple
Displacad Undisplacad
Avulsion frmures Cornpkated Uneompllcered
EPIPHYSEAL INJURIES Dispplacad Undispleced
0 c1 I7
I
17 0 0 0 O D c 5 0 0 5
DO ao 00 nu 00 El17 no on 00 no no
ON S3A
D O 0
CI a 0
0 0 0
0 U
U
a n
O D U
0 0
0 D O 0 0 t7 0 0 0 0 0
n
B
ON S3A
htln8NOlStJTI A0 ItlW N3d0 LZ:ST S00Z-92-130
~~
OCT-26-2865 15:37 OPEN MRI OF GLRSTONBURY * e ,
360 657 2264 P.07/15
WEST VaLUS IR HGSPI TI% SUPPLIMEivTRL FORM FUR DEPRRTMENT O F i?ADICJLOGY PROCEDURES:
KENNETt I ' 1 . HlNES JF!., MD lZ4 E. Welbourne G v e . Winter Park, FL 32793'
R R T E R I Q G R W H I C PROCEDURES
GBDOMINFIL RffRT17GRFIM THORFICIC GiORTQGRRM QBDOMINAL QQRTQGRRR + ZILFITERFIL
GXILLARY FPPROACH F O R NIRTFIGRflM
RENM QRfERiOGRRM RENRL VENOGRRM WITH RENINS V I S C E R A L aNGIUGRQPHY PULMONARY RkGIUG8APHY F t Q R T I C Rf7,:ki -+ CGROTID
;?NG ZOGRAPHY FlORTIC RRCH + 4 'JESSEL CEREBRRL
FINGI OGRRPHY n O R T I C RRCH + SUBCLAVIRN
RNGIDGAQPHY OTHER NQNCFlRDIFlC CWGIOGRfWHY
FEMORQL RUNQFF
WITH FEMORQL RUNOFF
DIGITAL IYTRaUENOUS INJECTIONS F U R STUDIES O F VEINS OR RRTERIES:
aRCH + CQROTID RRTERIES RRCH + CEREBRFIL QRTERIES FIBDOMINRL FIORTRGRAM OORTQGRFSM WITH FEMtJRClL RUNOFF FIORTFIGRFIM WITH R E N f X ARTERIES PULMONARY RNGIOGRPPHY UPE'ER E X T R E M I T Y VENOGRQM I
SUPERIOR VENA CAVAGRAM I N F E R l C l F i v E h G CPVRGRCtM Ft-V FISTULOGRRM
ILIQC QRTERIES SUPERFICIRL FEMORRL Q R T E R Y R E N N QRTERIES POPLITEX RRTERIES F'ROFUNDfi FEMQRRL QRTERY FEMCRAL-POPLITERL GRRFT STENUSIS OTHER PERIPHERFlL RNGICIPLQSTIES
!
OCT-26-2005 15: 37 OPEN MRI OF GLASTONBURY 860 657 2264 P.0W15 - ~ _ < .. . --7 -
I I !
! FISH MEMORIAL HOSPITAL
Office of the Registrar College of Medicine Univers i ty of F l o r i d a Gaiaeaville, Florida 32610
Dear Registrar:
245 EAST,NEW YORK AVENUE P.O. BOX 167
DELAND, FLORlDA 32'7234167 Telephone (904) 734-2323 March 2 , 1990
Both F i s h Memorial Kospital and West Volusia Memorial Hospital have received an application for Medical S t a f f appointrneqt with clinical p r i v i l e g e s from Kenneth K . Hines, Jr., M.D.
Dr. Hines indicates that he received his medical education at the College o f Medicine, University of F l o r i d a , graduating with h i e M.D. degree in June, 1984. Wou1.d you k i n d l y confirm t h i s kii,,? supply any additional information that may be he lpfu l to the Qualifications and Credentials Committees of che two hospitals-
Thank you for your a t t e n t i o n t o t h i s request.
/ Fish Memorial Hospital
This is to c e r t i f y t h a t Kennetb K. Hines, J r . attended the University of Florida. College of Medicine from September 8 , 1980 t o J u n e 1, 1984 and was graduated with the M.D. Degree, June 2, 1984.
Seni r Admissioas/Regis~ra~'s Office
March 13, 1990 Col1,ege P of Medicine
Direc tor of Post Graduate Study Department of Radiology E r i e County Medical Center 462 Crider Street Buffalo, New York 14215
Dear Director:
Kenneth K. Hines, Jr., M.D., has a p p l i e d t o Fish Memorial Hospital and Weat; Volusia Memorial Hospital f o r appointment to the Medical Staff with c l i n i c a l privileges in Diagnostfc Radiology at the two facilities. Dr. Hines states that he was affiliated with your institution as a participant is’ the Post Graduate Study (Residency) program in Radiology from J u l y , 1984, until June, 1988.
To aid us in thoroughly evaluating Dr. Hines’ capabilities and qualifications, we
A. Participant in your program from July 1 1984 t o June 30, 1988 3 3 . Succesafully completed? Yes x C. Any sanctions or other disciplinary actions taken agafnst the applicant during
request the following information:
No - h i s association with your facility? No If ”Yes ,I1 please explain:
!
Any other information you feel may be of help to us In considering t he applicant‘s appointment to our s ta f f s will be accepted with gratitude.
Date of Verification: 4/26/90
Person Verifying: George A l k e r , M.D.
Title: Professor €i Chairman, Dept of Radiology
-
Program Direc tor , Radiology Res idency Your prompt attention to this request will be appreciated by t h e applicant and by
the hcspitalr; . In accordance w i t h t h i s application until we have all
the Bylaws f o r each, w e cannot proceed further on of the r e l evan t information.
#ohn Allen Adminiatrator
OPEN MRI OF GLRSTONBURY 8613 657 2264 P . I W 1 5 OCT-26-2005 15:38 - ,.. ! i
, . - .
-.FFM H FISH MEMORIAL HOSPITAL
245 EAST NEW YORK AVENUE P.O. BOX 167
Telephone (904) 734-2323 DELAND, FLORIDA 32721-0167
March 2, 1990
Director of Post Graduate Study (Residency) Program Children's Hospital of Buffalo 219 Bryant S t r e e t Buffalo, New York 14222
Dear Director: I
Kenneth K. Hines, Jr., M.D., has applied ts Fish Memorial Hospital and West Volusia Memorial Hospital for appointment to the Medical S t a f f s with clinical privileges a t the two facilities, Dr. Hines states that he waa affiliated with your i n s t i t u t i o n as a participant in t he Post Graduate Study (Residency) program from July, 1988, to June, 1989.
To aid us is thoroughly evaluating D r . Hines' capabilities and qualifications, we
A. Parti.:: 1:. ::t in your program from
-i+: request the following information:
B. Successfully completed? Yes -- C. Any sanctions or other disciplinary actions taken against the applicant during
his association with your facility? W . If "Yes," please explain;
Any other information you feel may be of help to us in considering the applica * appointment to our staffs will be accepted with gratitude. 1&- - - Date of Verification: 3 - I J - 9 0 M- Person Verifylng:
T i t l e :
Your prompt ,... tencion to t h i s request will be appreciated by the applicant and by the hoapitals. Is accordance with the Bylaws for each, we cannot proceed f u r t h e r on t h i s application until we have all of the relevant information.
1,'' Administradar I
OCT-26-2885 15:38 OPEN M R I OF GLRSTONBURY e :
860 657 2264 P.11/15
Florlda Hospltal DeLand 701 W. Plymouth Avenue DeLand, Flotida 32720 ,
(386)9434865. --.__ . . .. . . . . - ...
2/11/2005
SU BJ ECT:
RE:
Verification of Hospital Privileges
Hines, Jr., Kenneth K , M.D.
Regarding the above named practitioner, a review of our rewrds indicates the following :
Medical Staff CategorylStatus: Active
DepartmentrSpeciaIty: Radiology & Nuclear Medicine/Radiology
Appo lntment Date: 311 211 990
Listed below are the current privileges of Dr. Hines, Jr. at Florida Hospital DeLand.
Amroved Privileges
Rcutine Radiographic procedures
Routine Flouroscopic procedures
Computerized tomography
Nuclear studies
Radio1 sotope Studies
1-31 Therapy
Upper GI Studies
Esophagram with cineradiography
Srnalf bowel studies
Barium enema studies
Kenneth Hines, Jr. Page: 1
~
OCT-26-2005 15:33 OPEN M R I OF GLASTONBURY 360 657 2264 P.12115 . .
Florida Hospital DeLand 701 W. Plymouth Avenue DeLand, Florida 32720
(38619434865 . _. . . . .- . . .-2/,..1,-20~~.. .... ~ .- . , . . . .. ._ _ _ . ._ .... - - , 1 . .. ..
Sialogram
Cholecystogram
Percutaneous chalangiograms
Fluoroscopic control and assistance with needle biopsy of organs
Injection of s inus tracts, fistula
or cysts with opaque media
IV pyelogram - plain and infusion
Urethrograms
Hystosalpingograms
Nuclear Cardiology
Mammography
Myelograms
Arthrograms
Cerebral arteriograms with cc catheter
or needle
Peripheral arteriagrarns, needle and catheter
Venogram - percutaneous and catheter
Aortograms - percutaneous and catheter
_.
Kenneth Hines, Jr. Page: 2
-.
OPEN MRI OF GLASTBNBURY S60 657 2264 P.13/15 OCT-26-2BB5 15:3S I .
Florida Hospital DeLand 701 W. Plymouth Avenue OeLand, Florida 32720
(386)943-4865 .,- _,-- --
2/1 l /2005 --- .--. - -1--
Ultrasonic diagnostic studies
Needle localization of breast lesions
lntradrterial Thrombolysis
Percutaneous Biliary Drainage and/or Stone Removal
Nephrostomy Procedures (including stone removal) ,
Biliary Lithotripsy
Percutaneous Stent Placement
Percutaneous Biopsies and Drainage Procedures
Stereotactic Breast Core Biopsy
Breast Aspiration
or Core Biopsy or FNABX
Transcatheter Embolization: ArteriesNeins
Ictra-arterial Petfussion Vasopression
Fercutaneous Transluminal Angioplasty
plus Sent Placement
Visceral Arteriograms
Pulmonary Arteriograms
Kenneth Hines, Jr. Page: 3
OCT-26-2005 15:38 OPEN MRI OF GLRSTdNEURY - . ’ 86@ 657 2264 P.14/15
Florida Hospital DeLand 701 W. Plymouth Avenue DeLand, Florida 32720
(386)943-4865
211 112005
IVC (Greenfield) Filter Placement
Percutaneous ArterialNenous Thrombolytic TX
Thoracentesis
Paracentesis
Central Line Placement
MRI - Imaging and Guided Biopsy
Moderate Sedation
End of Response
Kenneth Hines, Jr. Page: 4
OCT-26-2805 15:38 OPEN M R I OF GLASTONBURY I *
, c -\
860 657 2264 P.15/15
FLORIDA HOSPITAL DElAND MEDICAL STAFF REAPPOINTMENT SIGNATURE SHEET
“LUz
As Vice-chairman of the Department of Radlology, 1 have observed KENNETH K. HINES, JR., M.D., during the past reappointment period. Obligations of medical staff membership have been met. 5ased upon performance improvement monitors, performance of clinical skills, physical and emotional health and personal refationships with all professionals, I recommend reappointment to the Medical Staff with the clinical privileges requested, wlth the following exceptions:
I1 - Specify, with reason:
A-c7wc 11 Staff Category Recommended:
and all supporting documentatiqn and information, has been investigated and reviewed by the Credentials Committee, which recommends as follows:
I
Concurs with Recommendations from department Vice-Chair
Other II J
Chairman, Credentials/Committee Date -
This application, and all supporting documentation and information, has been investigated and reviewed by the Medical Executive Committee, which recommends as follows’
Concurs with Recommendations from Department Vice-Chair and Credentials Committee
..
- J
9hA03 Executive Date ;
Application for Medical Staff Reappointment, with clinical prlvileges recommended, including any limitations or exceptions as indicated, is APPROVED.
Other ,I II -
(SIG-RE. A PPI
TOTAL P. 15
This is t9 acknowledge the receipt of your letter/application dated
, and to inform you that the initial processing which includes an administrative review has been performed.
Pr rn~d( !~~~C. !A- Ob.-. (1 4 5 - 0 There were no administrative omissions. Your application was assigned to a technical reviewer. Please note that the technicalreview may identify additional omissions or require additional information.
Please provide to this office within 30 days of your receipt of this card
A copy of your action has been forwarded to our License Fee & Accounts Receivable Branch, who will contact you separately if there is a fee issue involved.
Your action has been assigned Mail Control Number 13A746 . When calling to inquire about this action, please refer to this control number. You may call us on (610) 337-5398, or 337-5260.
NRC FORM 532 (RI) (6-96)
Sincerely, Licensing Assistance Team Leader