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