Ill Southern Indiana Physicians August 7, 2017

U.S. Nuclear Regulatory Commission Materials Licensing Section 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352

Dear Sir or Madam:

Premier Healthcare, LLC would like to provide additional infonnation (control number 599820) regarding the notice of a transfer of control of its Byproduct Materials License, Number 13-32020-0 I, to IU Health Southern Indiana Physicians.

1. The Premier Healthcare group was acquired by IU Health Southern Indiana Physicians through a sales transaction whereupon all assets and liabilities were purchased, and whereupon the group is now doing business, under the IU Health Southern Indiana Physicians Tax ID. The transfer of control was effective May 1, 2017.

2. The requested relationship .diagram/description is attached. 3. The requested diagram/description showing a relationship with a license holder is

attached. 4. Use of radioactive materials will cease on September 1, 2017. 5. Items 5 through 10 of your request cannot be completed until materials use

ceases. 11. The requested materials referencing items 5-10 ofyour request will be provided

by September 8, 20 17.

If there are any questions concerning this license amendment, please contact Mr. Bryce A. Caudle, at 317-443-9035, by email at bcaudle@mpcphysics.com, or by fax at 317-581-1931.

Sincerely, ~

l?os~ Kay Fields, N .P. Chief Operating Officer Premier Healthcare, LLC 550 S. Landmark Avenue Bloomington, IN 4 7 403 812-353-4817

Elizabeth Thompson Administrator IU Health Southern Indiana Physicians Premier Multispecialty Group 550 S. Landmark Avenue Bloomington, IN 47403 812-353-4817

IU Health South Central Region leadership. 10/ 18/ 16

Regional Board of Directors

Matt Bailey President

South Central Region IU Health Bloomington

I Brian Shockney

coo

Mike Craig CFO

• Supply Chain • Integrated Care

• Program IU Health Bloomington

1- ---c - - - - - :: :·:~·:~'"' Ken Marshall, MD Chief Medical Officer

• Medical Education • Performance Excellence

• Risk Management • Clinical Research

Linda Lewis VP of Nursing

• Nursing Ops • Peri-operative

• E.D. • Women/ Children

• Oncology • Behavioral Health

• Spiritual • Clinical Education

• cv

Wendy Hernandez VP Professional/

Support • Food/ Nutrition

• Environmental Services • Radiology/ Pulmonary • Pharmacy • Lab • Ortho/ Neuro/ Rehab • Facilities/ Snow Removal • Security/ Emergency Mgt

Chuck Russo Transformation Officer

I

Bruce Wade VP of Human Resources

• Human Resources • Central Staff

Scheduling

Terl deMatas VP of Marketing and Community Relatfons

• Community Health • Volunteers

• Media Services • Print Shop

I Bradford Dykes

President IU Health Bedford

Regional Ambulance Services

I Brenda Davis

VP, Patient Services and CNO

I Larry Bailey

President IU Health Morgan

IU Health Paoli

I Jason King

VP, IU Health Morgan Patient Care Services

andCNO

Sonya Zeller VP, IU Health Paoli

COO and CNO

I Jon Barada

President Bloomington

Hospital Foundation

I . Mary Ann Valenta

Regional Director Strategic Integration

I Sandy DeWeese

coo IU Health

Southern Indiana Physicians

IIlii Indiana University Health

© 2016 IU Health 10/ 18/16

IU Health Southern Indiana Physicians - Organizational Chart. IU HEALTH SOUTHERN INDIANA PHYSICIANS BOARD OF

DIRECTORS\ Reports to IU~ Bloomington Board

Sandy DeWeese Chief Operating Officer .

Dave Burnworth Service Line

Administrator

Compliance/Privacy Officer

Mike Craig ;; Chief Financial Officer ............... ..........

IUHB & IUHSIP

Marlon Fishel Service Une Administrator

Primary Care (PC), Nephrology,

Scott· Rolfe

' Martinsville I

Multispecialty H·l Urgent Care, Urology, J

Service Line Administrator

Hospital Based Physicians

Group, Rheumatology I

Nicole Robinson Office Manager:

Martinsville Primary Care,

Martinsville ENT, Martinsville

General Surgery, Martinsville

Orthopedics & Sports Medicine,

Martinsville Women's Health

Teresa Allison Office Manager:

PC Bloomington Liberty & Nephrology

Alice Flick Office Manager: Walker Street

Rhonda Hendershot Office Manager:

PC Gosport & Spencer Jodi Killinger

Office Manager: PC Ellettsvil le Joyce McCracken

Office Manager: PC French Lick Andrea Meyer

Office Manager: Urgent Care Lori Owings

Office Manager: Urology Fred Schick

Office Manager: PC Bloomington Clarizz & Rogers

Jaimie Tague Office Manager: PC Nashville

Southern Indiana Physicians

Julia Wilhite Office Manager:

Emergency Medicine,

Palliative Care

Camille Nahas ································

Director of Human Resources

" Ellen Roth Service Line

Administrator Pediatrics,

Women's Health

Emily Koons Office Manager:

Pediatrics Arlington Rd.

Amanda Pruett Office Manager:

Pediatrics Bedford

Christina Roller Office Manager:

Pediatrics Martinsville

Chris Sherwood Office Manager:

Pediatrics Bloomington Landmark

Lori Terrell Office Manager:

Pediatrics Bloomington Clarizz

Melanie Neeley Office Manager:

Women's Health

..................... ~.---

Chip Johnson Service Line Administrator

Physician Services

Dave Sturgis Service Line

Administrator ENT, Foot & Ankle, General Surgery,

Neurology, Orthopedics & Sports Medicine Bloomington

Rachel Boruff Office Manager: ENT

Jenni Druckrey Office Manager: Foot &Ankle

Kristy Hayes Office Manager:

Neurology, Orthopedics

Bloomington Clarizz Bloomington YMCA

Jenise Roane Office Manager:

Ortho/ Joint Clinic

Shelly Wright Office Manager:

General Surgery Bloomington

.....

Lizzy Gentry Business Development

Consultant

Kelby Scrougham Communications

Coordinator

Sunny Slater;' Clinical Applications Support Manager

Bridgid Thomas Service Line

Administrator Bedford

Multispecialty Group (BMG),

Mitchell, & Paoli

Jennifer Blanton Office Manager:

Bedford Multispecialty Group, Paoli

Visiting Specialists

Group

Kristen Hutton Office Manager:

Bedford Multispecialty

Group

Elizabeth Thompson

Service Une Administrator Cardiology,

Oncology, Premier Multispecialty Group

Tami Anderson Office Manager:

PC, Walk-in Clinic, Gastroenterology,

Pulmonology, Endocrinology,

Infectious Disease Stephanie Beasley

Office Manager: Rheumatology & PC

Megan Flynn Office Manager:

Oncology Jenny Roberts Office Manager:

Card iology & CT Surgery

Jeff Sympson Facilities Manager

NRG,FORM 374 PAGE 1 OF _3_ PAGES U.S. NUCLEAR REGULATORY COMMISSION Amendment No. 72

MATERIALS LICENSE Pursuant to the .Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10, Code of Federal Regulations, Chapter I, Parts 30, 311 32, 33, 34, 35, 36, 37, 39, 40, 70, and 71, and in reliance on statements and representations heretofore made by the licensee, a license· is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and spe.cial nuclear material designated below; to use such material for the purpose(s) and at the place(s) designated below; to deliver or transfer such material to persons authorized to receive it In accordance with the regulations of the applicable Part{s). This license shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject to all applicable rules, regula! ns, and orders ot the Nuclear Regulatory Commission now or hereafter in effect and to any conditions specified below.

Licensee In accordance with letter dated January 28, 2016,

1. Indiana University Health Bloomington Hospital 3. License number 13-10408-02 is amended in its entirety to read as follows:

2. P.O. Box 1149 4. Expiration date November 30, 2020 f

A. kn · b>'product material . permitted by 1 o CFR 35.100 -

B. Any byproduct material · permitted ·by 10 CFR 35.200

C. AQy byproduct material permitted by 10 CFR 35.300

D. loalne-125 permitted by 10 CI7R 35.400

E. Palladi.um-1 03 permitted by 1 0 CFR B5.400

F. Cesiu -131 permitted by 10 CFR 35.400'

G. Any byproduct rn.?terial permitted by 1 0 CF.,R 31.11

9. Authorized use:

5. Docket No. 030-01644 Reference No.

7. Chemical and/or physical form

A. Any

B. Any

C. Any

D. Sealed ·sources (Best Medical IRternational, Inc. Model 2300 Series, 3M Health Physics ~ Services Model 6711, and Bard Brachytherapy Inc. Medel SJM 1251 )

E. Sealed sources (Tneragenics Cor,p. Thera Seed Model 200)

. • )1 ' ..

F .. SealeJ ·SQur,qe (lso~ay Model CS-1)

1 //J\ ' G. Prep'ack~·ged 'Kits > -·

A. Any uptake, dilution and excfr'Jtion study permitted by 1 q CFR 35~1 Ob. ~ r >-~ .... ,1'?-< r 1r

B. Any imaging and localization study perr1i itted pY · 0 CF~/35.200.

C. Any diagnostic study or therapy procedure permitted by 10 CFR 35.300.

8. Maximum amount that licensee may possess at any one time under this license

A.

B. As needed

C. 1 curie

D. 1.5 curies

E. 500 millicuries

F.

G.

D. through F. Any.manual brachytherapy procedure permitted by 10 CFR 35.400.

G. In vitro studies.

NRC FORM 374A · U.S. NUCLEAR REGULATORY COMMISSION PAGE 2 of 3 PAGES

MATERIALS LICENSE SUPPLEMENTARY SHEET

CONDITIONS

License Number

13-1 0408-02 Docket or Reference Number

030-01644

Amendment No. 72

10. A. Licensed material shall be used only at the licensee's facilities located at 605-625 West Second Street, Bloomington, Indiana.

B. Licensed material listed in ubitems 6.A. tH ough 6.C. ma~ also be used at the licensee's facilities located at 50.0 Lanamar Avenue, Bloomin to , lndi na.

C. Licensed materi·C'lllist~d in Subitem 6.C., limited to strontium-89, phosphorus-'32, and samarium-153, may be received ana used at the licensee's facilities located at 2620 Cota Drive, IJ1diana.

11. The Radiatio.n Safety Officer (RSO) for this license is Patrick J. Byrne, DABR, CHP, DABSNM.

A. lndividua.ls permitted to work as an authorized user in accordance with 10 CFR 35.13 and 35.14.

B. :rne following individuals are_ authorized users for medical use as indicated:

Authorized Users

David Y. Lee, M.D.

~ean M. F'lynn, M.D.

,,

Bruce N. Monson, M.D;.

John Alexander, M.D. ·--~!> " '

.. i 10 CF.R 35.3QO {limited to the oral administration of sodium iod.ide 1-131 i quantities less than or equal to 33 millicuries anct to the pa enteral aaministration of any beta emitter, r a. phofdn-einitting radion~elid.e with a photon energy less ·tl:tan 150 keV, 35.400, and .31 ,1j.

10 CFR 35.100, 35.200 35.300 ~limited to the oral adn)ihist ~ti,~~ of sodium iodide·l-131 in quantities ess than or

1 equ~( bt~3 \~llicuries), . and '31 .11.

,_,... 1 I \ \ \ -

110 1C ·R 35..1 0, 35.200, 35.300 (limited to the oral admilliSt(atio , of sodium iodide 1-131 in qyantities less than or equal to 33 millicuries), and 31 .11.

10 CFR 35.100, 35.200, 35.300 (limitecj to the oral administration of sodium ioaide 1-131 in quantities less than or

.~.1e~ual to )\3 millicu i@). artd 9f 11. \, . ""' - , v

.! , r . CFRj35"~ 00, 3J5.200, 35 .. 300 (limited to the oral aaministration of sodium iodide 1-131 in quantities less than or equal to 33 millicuries), and 31 .11.

NRG FORM 374A U.S. NUCLEAR REGULATORY COMMISSION PAGE 3 of 3 PAGES

MATERIALS LICENSE SUPPLEMENTARY SHEET

License Number

13-10408-02 Docket or Reference Number

030-01644

Amendment No. 72

Authorized Users Material and Use

Jonathan A Staser, M.D. 10 CFR 35.100, 35.200, 35.300 (limited to the oral administration of sodium iodide 1-131 in quantities less than or equal to 33 illicuries), and 31 .11 .

Jennifer Peterson Goldspiel, M .D. ~ 0 CFR 35. f oo.and 35.200.

Per Amundson, M.D. 10 CFR 35.100, 35.200, and 35.300 . . George K. Wolfer, Jr., M.D. 10 CFR 35.100, 35.200, 35.300 ( imited to the oral

administration of sodium iodide 1-131 in quantities less than or equal to 33 milliGuries ), and 31.11 .

NeaLDavid Abdullah , M.D. 10 CFR 35.100, 35.200, and 31.11 .

Todd A. Winkler, M.D. 10 CFR 35.100, 35.200, and 31.11 .

~icholas P. Miller, M.D., 10 CFR 35.100, 35.200, and 35.300 (limited to the oral administration of sodium Iodide 1-131 ).

13. Except as specifically provided otherwise in this·llcense, the licensee shall conduct its program in accordance with the statem~nts, representations,· and procedures contained in the documents, including any•enclosures, listed below. Th'is license con ition applies onl.y to those procedures that are reguireo to oe submitted in accordance with the regulations. Additionally, this licens_e condition does not lim1t the licensee's ability to make changes to the radiatien prote tion progfam as provided for in 10 CFR B5.26. The U.S. Nuclear Regulatory Commission's regulations shall govem unless the statements, representations, and procedures in the licensee's application and correspondence are more restrictive than the regulations.

A. Application dated June 11, 201 a· (ML 1 01750066) B. Letter dated M~rch . 13, 2012 (ML 1.2088A162, with attached facil ity diagram) C. Letter dated April 51.2013 (ML 13.1'01A144) D. Letter dated January 28, 2016 (ML 16077-A339) E. Letter dated March 20,.20~6 (ML:I6084A94,7)

I I I I F. Letter dated June 15,'2016 (ML 1616~A3921

1

" '

ItA \\J ~.

Date _ _ J_UN_15_2_0_16_

FOR THE U.S. NUCLEAR REG t:~TORY COMMISSION

1vz . _A ..! . f\J:r \

s~k t/1'. J:n£t.vu Sara A Forster, M.S. Materials Licensing Branch Region Ill

NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07·2012) 1°CFR 2.2o1 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION ·1. LICENSEE/LOCATION INSPECTED:

Indiana University Healtb Bloomington Hospital 606-625 West Second Street Bloomington, Indiana

REPORT NUMBER(S) 2016-00]

2. NRC/REGIONAL OFFICE

Region Ul U.S. Nuclear Regulatory Commission 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352

3. DOCKET NUMBER(S) 4. LICENSE NUMBER(S) 5. DATE(S) OF INSPECTION

030-01644 13-10408-02 May 25 , 2016

LICENSEE:

The inspection was ·an examination of the activities conducted under your license as they relate to radiation safety al)d to compliance with the Nuclear Regulatory. Commission (NRC) rules and regulations and the conditions of your license. The Inspection consisted of selective examinations of procedures and representative records,. interviews with personnel, and observations by the inspector. The inspection findings are as follows:

Based on the Inspection findings, no violations were identified.

Previous violation(s) closed.

The violations(s) , specifically described to you by the inspector as non-cited violations, are not being cited because they were self-identified, non-repetitive, and corrective action was or is being taken , and the remaining criteria in the NRC Enforcement Policy, to exercise

.. discretion, were satisfied .

Non-cited violatlon(s) were discussed invo.lving the following requirement(s) : ----

During this inspection, certain of your activities, as described below and/or attached, were in violation of NRC requirements and are being cited in accordance with NRC Enforcement Policy. This form is a NOTICE OF VIOLATION, whicl\ may be subject to posting in accordance with 10 CFR 19.11 . . (Violati9ns and Corrective Actions)

Statement of Corrective Actions I hereby state that, within 30 days, the actions described by me to the Inspector will be taken to correct the violations Identified. This statement of corrective 11ctions is m11de in llc;c:;ordanc;e with the require~nts of 10 CFR.2.201 (corrective· steps already taken, correclive steps' which will be LC!Iken, date when full compiiance will be achieved). I understand that no further written response to NRC will be required , unless specifically requested.

TITLE PRINTED NAME SIGNATURE DATE

LICENSEE'S REPRESENTATIVE

NRC INSPECTOR Geoffrey M. Warren

BRANCH CHIEF · Aa,ron r. McCraw

NRC FORM 591M PART 1 (07.-2012)

Gryglak, Magdalena

From: Sent: To: Subject:

Attachments:

Dear Magdalena,

Thompson, Elizabeth A <EThompson2@iuhealth.org> Thursday, August 10, 2017 9:28AM Gryglak, Magdalena; Bryce Caudle [Externai_Sender] RE: Request for Consent to Transfer of Control, NRC License no. 13-32020-01, Premier Healthcare, LLC South Central Region Leadership.docx; Organ izational Chart 2017 SIP.docx; US Nuclear Regulatory Commission Letter 8-7 -2017.pdf; N RC_License_Compliance.pdf; NRC_Materials_License.pdf; NM_IDHS_Registration.pdf

Attached are two org charts and other supporting documentation required as noted in the letter, which is signed . The two org charts show the regional organization structure based in Bloomington Hospital, the umbrella under which exists Southern Indiana Physicians {SIP), and the SIP org chart. The other three attachments are the documents showing the existing IU Health license with Bloomington Hospital.

Please let me know if you need any further information.

Elizabeth Thompson

Elizabeth Thompson Rademacher Service Line Administrator - Cardiology I Oncology 1 Premier Multispecialty Group 812-353-4817 c: 812-325-3676 1 Ethompson2@iuhealth.org

From: Gryglak, Magdalena [mailto:Magdalena.Gryglak@nrc.gov] Sent: Thursday, August 03, 2017 12:29 PM To: Bryce Caudle; Thompson, Elizabeth A Subject: Request for Consent to Transfer of Control, NRC License no. 13-32020-01, Premier Healthcare, LLC

****EXTERNAL Message From prvs=3811724bc=Magdalena.Gryglak@nrc.gov. DO NOT open attachments or click links from unknown senders or unexpected emails. **** Hello,

As discussed with Ms. Thompson on July 31, 2017, the attached document summarizes the information needed to proceed with the NRC review of your request.

Thank you

Magdalena R. Gryglak U.S. NRC, Region Ill 630-829-9875

1