Regulatory Analysis Form

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REVISED 12/16 Regulatory Analysis Form (Completed by Promu!gating Agency) f (AllCommentssubmitted onthisregulation willappear on IRRC’swebsite) JUN 2020 (1) Agency 15 Department of State, Bureau of Professional acid Occupational IndependentRegulatory Affairs, State Board of Osteopathic Medicine Review Commission

(2) Agency Number: 16A IRRC Number: 3254 Identification Number: 5334

(3) PA Code Cite: 49 Pa. Code §25.23 1 and 25.503

(4) Short Title: Fees

(5) Agency Contacts (List Telephone Number and Email Address): Primary’Contact: Kenneth J. Snter, Board Counsel, State Board of Osteopathic Medicine. P.O. Box 69523, Harrisburg, PA 1711)6-9523(phone 717-783-7200) (fax 717-787-0251) ksuter:pa.gov

Secondary’Contact: Jacqueline A. Wolfgang, Acting Senior Regulatory Counsel, Department of State, P.O. Box 69523, Harrisburg. PA 17106-9523 (phone 717-783-7200) (fax 717-787-0251) jawoIfgang:pa.gov

(6)Type of Rulemaking (check applicable box): U Emergency Certification Regulation; Final Regulation U Certification by the Governor U Certification by the Attorney General

(7) Briefly explain the regulation in clear and nontechnical language. (100 words or less)

The State Board of Osteopathic Medicine (“Hoard”) amends § 25.231 (relating to schedule of fees) and to rescind § 25.503 (relating to fees) to read as set forth in Annex A. The rulemaking provides for graduated application fees increases for: osteopathic physicians, short—term camp osteopathic physicians, temporary training licenses or graduate training certificates, physician assistants, supervising osteopathic physicians, acupuncturists and physician acupuncturist, respiratory therapists, athletic trainers. perfusionists, reactivation of perfusionist licenses, temporary graduate perfusionist licenses, temporary provisional perfusionist licenses, genetic counselors, genetic counselor reactivations and temporary provisional genetic counselors.

The rulemaking also implements graduated biennial renewal fee increases for osteopathic physicians, physician assistants, acupuncturists, perfusionists, athletic trainers, respiratory therapists and genetic counselors. (8) State the statuton’ authority for the regulation. Include specific statutory citation.

Under section 16 of the Osteopathic Medical Practice Act (act) (63 P.S. § 271.16), the Board has the “power to adopt and revise such regulations as are reasonably necessary to carry out the purposes of this act in conformity with the provisions of the act of July 31, 1968 (P.L. 769, No. 210), known as the “Commonwealth Documents Law.” Under section 13.1(a) act, (63 P.S. § 271.13a(a)), the Board is required to support its operations from the revenue it generates from fees, fines and civil penalties. Under the act, all fees required pursuant to the act shall be fixed by the board by regulation and shall be subject to the act of June 25, 1982 (P.L.633, No.181), known as the “Regulatory Review Act.” If the revenues raised by fees, fines and civil penalties imposed under this act are not sufficient to meet expenditures over a two-year period, the board shall increase those fees by regulation so that the projected revenues will meet or exceed projected expenditures. 63 P.S. § 271.13a((a). All “fees, fines and penalties imposed . . shall be for the exclusive use by the board in carrying out the provisions of this act and shall be annually appropriated for that purpose.” 63 P.S. §271.13a(c).

(9) Is the regulation mandated by any federal or state law or court order, or federal regulation? Are there any relevant state or federal court decisions? If yes, cite the specific law, case or regulation as well as, any deadlines for action.

Yes. Section 13.1(a) of the act mandates a fee increase when expenditures outpace revenue.

(10) State why the regulation is needed. Explain the compelling public interest that justifies the regulation. Describe who will benefit from the regulation. Quantify the benefits as completely as possible and approximate the number of people who will benefit.

The act requires the Board to set fees by regulation so that revenues meet or exceed expenditures. The general operating expenses of the Board are borne by the licensee population through revenue generated by applications and the biennial renewal of licenses. The final-form rulemaking ensures the fiscal integrity of the Board and allows the Board to carry out its mission.

The majority of the Board’s costs are personnel related, and much of those costs are not within the Board’s control. Staff are generally employees of the Commonwealth, most of whom are civil service personnel, and many are union positions. For these employees, the Board is hound by the negotiated contract. Personnel costs associated with investigation and enforcenient depend largely on the number of complaints received that need to be investigated, and the number of those matters that result in disciplinary action. The Board has no control over the number of complaints that are filed against licensees and unlicensed individuals, nor may they control which matters are or are not prosecuted.

Over the last few fiscal years, the Board has had sonic sizable increases to expenses for a variety of reasons. One of the largest financial impacts for the Board was the incorporation of The Pennsylvania Justice Network (JNET). due in part to the enactment of act of February 15, 2018 (P1. 14, No. 6) (Act 6 of 2018), which requires mandatory self-reporting of crintinal convictions. The Board uses JNET to identify criminal convictions of licensees and to verify compliance with Act 6 of 2018’s mandatory reporting requirement. Initially, the Board was one of three (3) boards under the Bureau that incorporated JNET criminal notifications into their business processes. Across the three (3) boards, there was a sizable 27.5% average increase in the number of complaints being processed and opened for prosecution. With the additional complaints,

7 increased expenses due to higher prosecutions, investigations, expert witness usage, and hearings resulted. Since incorporation of JNET, expenses have been relatively steady in all of these cost categories. More than likely, this new level of legal workload is one that will be part of the financial picture for the Board going forward.

In addition to the legal increases, all 29 boards and commissions under the Bureau have undergone an information technology transformation upgrade with the incorporation of the Pennsylvania Licensure System (PALS). Expenses associated with PALS, including the initial build as well as ongoing maintenance, are proportionately spread across all entities based on licensee population as a way to effectively share costs per licensee. While the initial build is in the past, it has contributed to higher administrative expenses for all boards during the last few fiscal years. Due to PALS’ high functioning database with enhanced features over the Department’s previous License 2000 platform, maintenance for this system requires a larger financial commitment from all boards and commissions than the previous system.

One of the major reasons this Board requires considerable increases is due to it being a standalone appropriation without any reliance on the Professional Licensure Augmentation Account (PLA1). In the early 2000’s, this Board, along with the State Board of Medicine, increased fees to handle the potential influx of cases under the Medical Care Availability and Reduction of Error Act (MCARE Act) (40 P.S. § 1303.101—1303.910). Thankfully, the Board did not incur the amount of expenses initially projected, leaving the Board with larger than normal revenue surpluses. In 2011, the Board decided to reduce biennial renewal fees to level the large surpluses in their respective restricted account. While this was a short-term solution, expenses outlined previously, had quickly tipped the scales and left the Board in a situation where revenues were no longer meeting expenditures.

The Board receives an annual report from the Department of State’s Bureau of Finance and Operations (BFO) regarding the Board’s income and expenses. Currently, the Board’s revenue and expenses for fiscal years (FY) 2016-2017 and 2017-18 and the projected revenue and expenses through F’ 2027—2028are as follows: during F’ 2016-2017 through 2017-2018, the Board received revenue of $2,128,270.14 and incurred expenses of $3,221,243.36 and ended with a remaining balance of $1,712,593.53. For FY 2018-2019 through 2019-2020, the Board projects receiving revenue of $2,233,122.60 and projects incurring expenses of $3,545,185.74. At tile end of Fl’ 2019-2020, BFO projects a remaining balance of 5400,530.39, which is only enough to cover approximately 3 months of expenditures. For FY 2020-2021 through Fl’ 2021-2022, without an increase in fees, the Board projects revenue of 52.339 million and projects expenses of S3.804 I million, with a deficit balance in Fl’ 2021-2022 of ($1,064,469.61). Thus, BFO’s data demonstrates that the Board’s revenue is not sufficient to meet or exceed its expenditures over a 2-year period in fiscal year 2019-2020 or thereafter. Seven graduated biennial renewal fee increases will be implemented under the final-form rulemaking. Biennial renewal fee increases will be implemented for: osteopathic physicians, physician assistants, acupuncturists, respiratory therapists, athletic trainers, perfusionists, and genetic counselors. Approximately 12,721 individuals who possess current licenses, certificates and registrations will be required to pay more for biennial renewals. While licensed individuals will be impacted economically, the graduated increase as opposed to a flat fee increase vilI ensure that fees charged coincide more closely with the projected expenses for each biennium. As a part of the Board’s rulemaking, the Board reviewed the fees charged for licensure applications and determined that the current application fees do not accurately reflect the actual cost of processing applications. Accordingly, the Board also adopted increases in application fees

3 so that the application fees more accurately reflect the cost of processing applications. Increasing the application fees, however, does not produce sufficient revenue to meet or exceed the Board’s projected expenditures. The rulemaking will increase licensure application fees to reflect updated costs of processing applications. The following application fee increases will be implemented under the final—form rulemaking: osteopathic physicians, short-term camp osteopathic physicians, temporary training licenses or graduate training certificates, physician assistants, supervising osteopathic physicians, acupuncturists and physician acupuncturist, respiratory therapists, athletic trainers, perfusionists, reactivation of perfusionist licenses, temporary graduate perfusionist licenses, temporary provisional perfusionist licenses, genetic counselors, genetic counselor reactivations, and temporary provisional genetic counselors. Approximately 2,600 applicants will be impacted by this regulation. While applicants will be impacted economically, the graduated increase as opposed to a flat fee increase to ensure that fees charged to licensees are reflective of costs for processing each application. The new fee structure is projected to produce biennial revenues of: $3.949 million in FY 2020- 2021 through 2021-2022, which will allow the Board to meet or exceed its projected expenditures of $3.804 million; 54.938 million in FY 2022-2023 through 2023-2024, which will allow the Board to meet or exceed its projected expenditures of $3.918 million; and $5.3 14 million in FY 2024- 2025 through 2025-2026, which will allow the Board to meet or exceed its projected expenditures of $4.036 million, and will return the Board to a fiscally sound position. The Board believes that the fees ‘viii be adequate to cover operating expenses through at least fiscal year 2025-2026.

The fee increases for application and biennial renewal fees will enable the Board to continue to create a small surplus in funds in their restricted account should there be any additional unknown financial impacts. The final-form rulemaking will benefit every citizen of the Commonwealth in that it ensures the fiscal integrity of the Board so that it can carry out its mission. The costs to applicants and licensees are outweighed by the Board’s duly to license and regulate the practice of osteopathic medicine in the public interest.

(11) Are there any provisions that are more stringeni than federal standards? If yes, identify the specific provisions and the compelling Pennsylvania interest that demands stronger regulations.

No, there are no federal licensure standards for osteopathic medicine.

(12) How does this regulation compare with those of the other states? How will this affect Pennsylvania’s ability to compete with other states?

In 2018, the Commissioner of the Bureau of Professional and Occupational Affairs (Bureau) issued an executive report on the Review of State Professional and Occupational Licensure Board Requirements and Processes. The report compares professional licensing in Pennsylvania to states in the Northeast Region (Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Ohio, Rhode Island, Vermont and Vest Virginia). The report can be found at: https://www.dos.pa.gov/ProfessionalLicensintj/Docu ments/E020 17—03—Executive—Report— Occupational-Licensin2.pdf

The Board reviewed the Commissioner’s report and the U.S. Osteopathic Licensure Summary by American Osteopathic Association (September 2019). Based upon the Board’s review of other

4 states’ initial application fees as compared to the Board’s fee increases, the rulemaking will riot put Pennsylvania at a competitive disadvantage with other states.

Osteopathic Physician — Pennsylvania, Maine, Vermont and Vest Virginia are the only states in the Northeast Region that have separate osteopathic physician licensing hoards. Of this group, based upon the Board’s application fee of $170, Pennsylvania would have the lowest initial licensing/registration fee, compared to Maine at $350, Vermont at $500 and West Virginia at $400. Even comparing the other states’ current fees to the Board’s 2022 increase to $185 and 2024 increase to $205, the Board’s fees will he less than fees charged by the other states.

Pennsylvania’s biennial renewal fee of $330 (effective with the 2020-2022 biennial renewal) is lower than Maine at $500, West Virginia at $400, and Vermont at $350. Even comparing the other states’ current renewal fees to the Board’s 2022-2024 and 2024—2026biennial renewal fee increases, the Board’s renewal fees of $420 and $450 are in line with fees charged in the other states.

Physician Assistant — Pennsylvania’s application fee is SI 15 in 2020, $125 in 2022, and $140 in 2024. Pennsylvania would have a competitive application fee of $115, equal to New Hampshire and New York fees of $115. The current fees for other states in the Northeast Region are: Rhode Island at SIlO, Connecticut at $190, Delaware at $253, Maine at $250, Maryland at $225, Massachusetts at $250, New Jersey at $362.50, Ohio at $503.50, Vermont at $225 and West Virginia at $250. Most of the surrounding states charge higher fees than Pennsylvania’s fee of $115, and the remaining states are comparable to Pennsylvania’s initial increase. Even comparing the other states’ current fees to the Board’s subsequent application fee increases, the Board’s fees of $125 (in 2022) and $140 (in 2024) are less than or comparable to other states.

Pennsylvania’s biennial renewal fee of $40 (effective with the 2020—2022biennial renewal) is lower than, or comparable to, neighboring states. By comparison, the current renewal fees for other states are Connecticut at $155, Delaware at $188, Maine at $200, Maryland at $186, Massachusetts at $150, New Hampshire at $65, Rhode Island at $110, Ohio at $203.50, Vermont at $215, West Virginia at $100, and New Jersey and New \‘ork at $45. Even comparing the other states’ current renewal fees to the Board’s subsequent renewal fee increases that will take place in 2022-2024 ($75) and 2024-2026 ($80), the Board’s new renewal fees are less than, or comparable to, renewal fees charged by the other states.

Acupuncturist and Physician Acupuncturist - Pennsylvania’s application fee is $100 in 2020, SI 10 in 2022, and $120 in 2024. Initial application fees in other states are: Connecticut at $200, Delaware at $188, Maine at $396, Maryland at $525, Massachusetts at $300, New Hampshire at $110, New Jersey at $370, New York at $788, Ohio at $173.50, Rhode Island at $310, Vermont at $100, and Vest Virginia at $500. IIost of the surrounding states’ fees are either comparable to or higher than Pennsylvania’s new fees. Even comparing the other states’ current fees to the Board’s subsequent application fee increases, the Board’s new fees of $110 (in 2022) and $120 (in 2024) are less than most of the states.

Pennsylvania’s biennial renewal fee of $40 (effective with the 2020-2022 biennial renewal) is significantly lower than the other comparison states. The current renewal fees for other states are Connecticut at $255, Delaware at $188, Maine at $195, Maryland at $551, Massachusetts at $200, New Hampshire at $110, New York at $288, Rhode Island at $310, New Jersey at $270, Ohio at $100, Vermont at $200, and West Virginia at $425. Even comparing the other states’ current

5 renewal fees to the Board’s subsequent renewal fee increases that will take place in 2022-2024 ($75) and 2024-2026 ($80), the Board’s renewal fees are less than other states.

Respiraton Therapists - Pennsylvania’s application feels $100 in 2020, SIlO in 2022, and $120 in 2024. Initial application fees in other states are: Connecticut at $190, Delaware at $108, Maine at $86; both Maryland and West Virginia at $200; Massachusetts at $260, New Hampshire at S170, New Jersey at $285, and New York at $294, Ohio at $75. Rhode Island at $60 and Vermont at SIOU. By comparison, Pennsylvania’s fees are less than, or comparable to, other fees in tile Northeast Region. Even comparing the other states’ current fees to the Board’s subsequent application fee increases, the Board’s fees of $110 (in 2022) and $120 (in 2024) are less than most other states.

Pennsylvania’s renewal fee of $40 (effective with the 2021-2022 biennial renewal) would be lower titan the other comparison states. Renewal fees for other states are: Connecticut at $105, Delaware at $108, Maine at $65, Maryland at $176, both Massachusetts and New Hampshire at $110, New Jersey at $160, New York at $179, Ohio at $75, Rhode Island at $60, Vermont at $200, and West Virginia at $55. Even comparing the other states’ current renewal fees to the Board’s subsequent renewal fee increases that will take place in 2023-2024 and 2025-2026, the Board’s renewal fees of $55 and $60 would be lower than most of the other states.

Athletic Trainer — Pennsylvania’s application fee is $100 in 2020, SI 10 in 2022. and $120 in 2024. Pennsylvania would have a competitive application fee as compared to other states. The fees in other states are: Connecticut at $190, Delaware at $198, Maine at $196, Maryland at $200, Massachusetts at $259, New Hampshire at $170, New Jersey at $140 to $180, depending on biennial year, New York at $158, Ohio and Vermont at $101),and West 7irginia at $125. Rhode Island has the lowest fee of $60. Even comparing the other states’ current fees to the Board’s subsequent application fee increases, the Board’s fees of SIlO (in 2022) and $120 (in 2024) are less titan or comparable to fees charged in other states.

Pennsylvania’s biennial renewal fee of $50 (effective with the 2021-21)22 biennial renewal) is lower than Connecticut at $205, Delaware at $198, Maine at $150, Maryland at $161, Massachusetts at $101),New Hampshire at $1 II), New Jersey at $80, New York at $50 (triennial renewal), Ohio at $70, Rhode Island at $60, Vermont at $200 and West Virginia at $75. Even comparing tile other states’ current renewal fees to the Board’s subsequent renewal fee increases that will take place in 2023-2024 ($70) and 2025-2026 ($75), the Board’s renewal fees are less than or comparable to other states.

Perfusionist - Pennsylvania’s application fee is $120 in 2020, $130 in 2022, and $145 in 2024. Delaware, Maine, New Hampshire, Ohio, Rhode Islatid, Vermont and Vest Virginia do not issue licenses to perfusionists. Of those states that do license perfusionists, the current fees are: Connecticut at $315, Maryland at $300. Massachusetts at 5225, New Jersey at $370, and New York at $200. By comparison, Pennsylvania will have the lowest application fee in the Northeast Region. Even comparing the other states’ current fees to the Board’s subsequent application fee increases, the Board’s fees of $130 (in 2022) and $145 (in 2024) are less titan other states.

Peitusylvania’s biennial renewal fee of $75 (effective with the 2021—2022biennial renewal) is significantly lower titan the other comparison states, for example, Connecticut at S320, Maryland at $247, Massachusetts at $150, New Jersey at $150, and New York at $150. Even comparing the other states’ current renewal fees to the Board’s subsequent renewal fee increases that will take

6 place in 2023-2024 and 2025-2026, the Board’s renewal fees of $80 and $85 are less than other states.

Genetic Counselor - Pennsylvania’s application fee is $120 in 2020, $130 in 2022, and $145 in 2024. Maine, Man-land, New York, Rhode Island, Vermont and Vest Virginia do not issue licenses to genetic counselors. Of those states thai do license genetic counselors, the current fees are: Connecticut at $315, Delaware at $253, Massachusetts at $300, New Hampshire at $170, New Jersey at $250, and Ohio at $203.50. By comparison, Pennsylvania would have the lowest initial licensing/application fee of $120 in the Northeast Region. Even comparing the other states’ current fees to the Board’s subsequent application fee increases, the Board’s fees of $130 (in 2022) and $145 (in 2024) are less than other states.

Pennsylvania’s renewal fee of $125 (effective with the 2021-2022 biennial renewal) renewal fee would be lower than other states. The current renewal fees for other states are: Connecticut at $190, Delaware at $188, Massachusetts at $300, New Jersey at $220 and Ohio at $153.50. New Hampshire has the lowest fee of SIlO. Even comparing the other states’ current renewal fees to the Board’s subsequent renewal fee increases that will take place in 2023-2024 and 2025-2026, the Board’s renew-al fees of $155 and $160 are less titan or comparable to other states. l3) \ViII the regulation affect any other regulations of the promulgating agency or other state agencies? If yes, explain and provide specific citations.

No.

(14) Describe the communications with and solicitation of input from the public, any advisory council/group, small businesses and groups representing small businesses in the development and drafting of the regulation. List the specific persons and/or groups who were involved. CSrnall business” is defined in Section 3 of the Regulatory Review Act, Act 76 of 2012.)

The Board released an exposure draft of a proposed annex reflecting fee increases for public comment from stakeholders, interested parties and representatives of the licensed professions on May 8,21118. The Board also discussed the proposed rulemaking on February 14, 2018, April 11. 2018, August 22, 2018, October 24, 2018, February 13, 2019, August 14, 2019, and December 11, 2019, during the Board’s regularly scheduled meetings which are routinely attended by representatives of the regulated community. Notice of the proposed rulemaking was published at 50 Pa.B. 1364 (March 7, 2020). Publication was followed by a 30-day public comment period during which the Board received 36 public comments, including comments from the Pennsylvania Osteopathic Medicine Association (POMA) and the Pennsylvania Medical Society (PAMED). In addition, the House Professional Licensure Committee (HPLC) submitted comments, and the Independent Regulatory Review’ Commission (IRRC) also submitted comments. The Senate Consumer Protection and Professional Licensure Committee (SCP/PLC) did not submit comments. The Board review-ed all comnients during its regularly scheduled meeting on June 10, 2020 and adopted the final rulemaking after consideration of the comments. A list of the public commenters is attached as Attachment “A.”

Regarding comments received, POMA and PAMED were generally supportive of the proposed regulation, but voiced concern about the timing of the regulation and whether there was sufficient time to promulgate the regulation prior to the upcoming November I, 2020—October

7 31, 2022 biennial renewal period. While the Board acknowledges that the turnaround time between the proposed rulemaking and the final rulemaking is ambitious, the Board remains committed to do the work necessary to promulgate the regulations within sufficient time to process renewal notices for the November 1, 2020—October 31, 2022 biennial renewal period. The Board has historically sent out renewal notices approximately 60 days prior to the date of the expiration of licenses. The Board’s anticipates sending renewal notices by the beginning of September. Assuming both IRRC and the Office of Attorney General approve the rulemaking, the Board believes it will be able to promulgate the regulation in time to send the renewal notices out within the 60-day period. Almost all of the public comments were from physicians and most physicians opposed the increase in physician fees or asked the Board to decrease the size of the fee increase. Regarding application fees, the increase in physician application fees is designed to cover the cost to process applications. This fee is borne by md ividnal applica nts. Subsequent increases are calculated at a 9.5% increase as pay increases for staff that l0t applications are 2.5% in .July and 2.25% in .Janua ry or 4.75% anitually (9,5% biennially) and the fee is almost entirely dependent upon personnel-related costs. For osteopathic physicians, the $45 application fee has been in place since January 29, 2000. Raising the application fees for physicians to $170 reflects the cost of processing the application. This fee increase is appropriate so that the applicants, and not existing licensees, bear the cost of processing those applications.

Regarding the increase in biennial renewal fees, the Board is dutybound to ensure that the Board is fiscally sound. By the end of Fl’ 2021-2022, BFO anticipates that the Board will be in a deficit, and thus, increasing fees is critical to sustain the operations of the Board. The Board is statutorily obligated to increase fees by regulation when revenues raised by fees, fines and civil penalties under the act are insufficient to meet expenditures over a two-year period. The Board meets this criterion, and thus, is required to increase its fees. Notwithstanding the need to increase fees. given some changes in the Board’s expenditures and revenues due in part to the COVID-19 pandemic, BFO reviewed updated fiscal revenue and expenditures data after the proposed rulemaking was published. BFO found that, in addition to increases in the revenue and licensee count, the expenses incurred by the Board during the pandemic have decreased. While the fee increases are still needed prior to the next renewal period for the Board to remain solvent, the Board was able to decrease the renewal fees for physicians to ease the burden. As reflected in Annex A, the biennial renewal fees for osteopathic physicians were adjusted down front $350 to $330 in the November 1,2020—October 31, 2022 biennial renewal period; front $425 to $420 in the November 1, 2022—October 31, 2024 biennial renewal period; front $475 to $450 in the November 1,2024—October 31, 21)26biennial renewal period.

The Board received several public comments opposing the increases in fees because of the COVID-19 paudentic. Commenters suggest to the Board that fees should not be raised during the pandentie. Sonte commenters opined that raising fees for physicians would cause financial hardship. in part, because physicians have suffered a negative financial impact due to the pandemic as a result of cancelled appointntents, cancelled elective surgeries, and laying off staff. PAI%IEDand one commenter asked if the Board was prepared to delay or cancel the fee increase. IRRC also commented and expressed concern that the fee increases will cause financial harm during the pandemic and asked the Board to withdraw the rulemaking and resubmit it at a later date. Similarly, the HPLC submitted a comment recommending that the fee increases contained in the proposed regulation be delayed until after the end of the COVID-19 entergeney.

While the Board understands the impact the pandemic has had on its licensees, including the

8 negative financial impact that has occurred to the regulated community, the Board’s work in proposing the fee increase began long before the pandemic. The Board is statutorily mandated to increase fees by regulation if the projected revenues will not meet or exceed projected expenditures. Delaying the collection of fees is not fiscally feasible because the Board projects that it will be in a deficit situation by the end of F\’ 2020-2021. As indicated above, the fee increase is necessary due to expected increases in personnel costs, sizable increases to expenses, including the implementation of JNET notifications which caused a 27.5% average increase in the number of complaints across the three boards (including the Board) that implemented the JNET notifications, and technology upgrades and maintenance of the new database. The fee increases for application and biennial renewal fees will enable the Board to continue to create a small surplus in funds in their restricted account should there be any additional unknown financial impacts.

(15) Identify the types and number of persons, businesses, small businesses (as delined in Section 3 of the Regulatory’ Review Act, Act 76 of 2012) and organizations which will be affected by the regulation. How are they affected?

On an annual basis, approximately 2,600 applicants will he affected by the following increased application fees: osteopathic physicians, short-term camp osteopathic physicians, temporary training licenses or graduate training certificates, physician assistants, supervising osteopathic physicians, acupuncturists and physician acupuncturist, respiratory therapists, athletic trainers, perfusionists, reactivation of perfusionist licenses, temporary graduate and provisional perfusionist licenses, genetic counselors, genetic counselor reactivations, and temporary provisional genetic counselors.

A total of approximately 12,721 licensees will be affected by the biennial renewal fee increases, comprising of approximately 9,009 physicians and supervisors, 2,603 physician assistants, 159 acupuncturists, 560 respiratory therapists, 39 perfusionists, 25 genetic counselors and 326 athletic trainers.

According to the Small Business Administration (SBA), there are approximately 1,011,905 businesses in Pennsylvania; of which 1037,737 are small businesses. Of the 1,037,737 small businesses, 225,847 are small employers (those with fewer than 500 emploees) and the remaining 811,890 are non-employers. Thus, the vast majority of businesses in Pennsylvania are considered small businesses.

According to the Pennsylvania Department of Labor and Industry, based on data collected in 2016, about half of physicians work in physicians’ offices. Others work iii hospitals, in academia, or for the government. Physicians held about 713,800 jobs in 2016. Many physician assistants work in primary care specialties, such as general internal medicine, pediatrics, and family medicine. Specifically, the majority of physician assistants work in offices of physicians (56%) while a minority work in hospitals. state, local, and private (23%), outpatient care centers (B%), educational services: state, local, and private (3%), and employment services (3%). The largest employers of athletic trainers are educational services- state, local, and private (38%), while others are employed in offices of physical, occupational and speech therapists, and audiologists (15%), hospitals- state, local, and private (15%), fitness and recreational sports centers (10%), and self-employed (6%). The largest employers of genetic counselors are hospitals - state, local, and private (33%), while others are employed in offices of physicians (20%), medical and

9 diagnostic laboratories (18%), colleges, universities, and professional schools- state, local, and private (11%). and self-employed (8%). Respiratory therapists held about 130,200 jobs in 2016. The largest employers of respiratory therapists were as follows: hospitals; state, local, and private (81%), nursing care facilities (skilled nursing facilities) (5%), offices of physicians (2%). Respiratory therapists work closely with registered nurses, physicians, and medical assistants. There is no specific data collected for acupuncturists or perfusionists.

For the business entities listed above collectively, small businesses are defined in Section 3 of the Regulatory Review Act, (71 P.S. § 745.3) which provides that a small business is defined by the SHA’s Small Business Size Regulations under 13 CFR Cli. I Part 121. These size standards have been established for types of businesses tinder the North American Industry Classification System (NAICS). In applying the NAICS standards to osteopathic medicine, the standard set for offices of physicians (NAICS Code 621111) to qualify as a small business is $12 million or less in average annual receipts. Also, in the NAICS category for general medical and surgical hospitals (NAICS Code 622110) to qualify as a small business is $41.5 million or less in average annual receipts. Other businesses in the NAICS small business category include colleges, universities and professional schools (NAICS Code 611310) with annual receipts of $30 million or less, all other outpatient care centers (NAICS Code 621498) with annual receipt of $22 million or less, nursing care facilities (skilled nursing care facilities) (NAICS Code 623110) with annual receipts of $30 million or less, offices of physical, occupational and speech therapists and audiologists (NAICS Code 621340) with annual receipts of 58 million or less, fitness and recreational spoils centers (NAICS Code 713940) with annual receipts of $8 million or less, and medical laboratories (NAICS Code 621511) with annual receipts of 535.0 million or less. Although the Board does not collect data regarding the size of businesses where its licensees work, iii considering all of these small business thresholds set by NAICS, it is probable that most work in small businesses.

The regulation’s impact should not extend to those businesses as there are no direct costs that would he passed on to the licensee’s employer, unless the employer voluntarily assumes those costs. It would, therefore, he up to the business to determine the benefit of paying employee licensing fees.

(16) List the persons, groups or entities, including small businesses, that will be required to comply with the regulation. Approximate the number that will be required to comply.

The amendments will increase the application and biennial renewal fees for all licensee/certificate holders of the Board. Specifically, those affected are:

APPLICANTS - Approximately 2,600 applicants will be impacted annually by the increased application fees, including: 1,200 osteopathic physicians; 600 temporary or graduate trainees; 60 short—term camp phsicians; 500 physician assistants; 51 supervising physicians; 13 acupuncturists and physician acupuncturists; 10 perfusionists; 5 perfusionists seeking reactivation; 1 temporary graduate perfusionist; 3 temporary provisional perfusionist; 80 athletic trainers; 50 respiratory therapists; 10 genetic counselors; 5 genetic counselors seeking reactivation; and 15 temporary provisional genetic counselors.

LICENSEES/CERTIFICATE HOLDERS (Biennial Renewal) - There are approximately 12,721 individuals who will be required to pay more to renew their licenses, certifications and registrations, including 9,009 physicians; 2,603 physician assistants; 159 acupuncturists and physician acupuncturists; 25 genetic counselors; 39 perfusionists; 326 athletic trainers and 560

10 respiratory therapists.

The fees may be paid by applicants, licensees, certificate holders or employers, if employers choose to pay these fees. The regulation should have no other fiscal impact on the private sector, the general public or political subdivisions of the Commonwealth.

The rulemaking will require the Board to alter its online applications to reflect the new fees; however, the amendments will not create additional paperwork for the regulated community or for the private sector.

(17) Identify the financial, economic and social impact of the regulation on individuals, small businesses, businesses and labor communities and other public and private organizations. Evaluate the benefits expected as a result of the regulation.

The Board proposes to amend §25.231 to update its fee schedules. The amendments will increase the application and biennial renewal fees for licensees of the Board. Specifically, those affected are as follows:

APPLICANTS

Approximately 2,600 applicants will he impacted annually by the graduated application fee increase.

1.200 Osteopathic Physicians

Fl’ 20-21: The fee increase ($45 to S170) will generate an additional 5150,0W) in application fees. FY 21-22: The fee increase will continue to generate an additional 5150,00(1in application fees. FY 22-23: The fee increase ($170 to $185) will generate an additional $18,000 in application fees. FY 23-24: The fee increase will continue to generate an additional $18,000 in application fees. FY 24-25: The fee increase ($185 to $205) will generate an additional $24,000 in application fees. FY 25-26: The fee increase will continue to generate an additional $24,000 in application fees.

60 Short-term Camp Physicians

FY 20-21: The fee increase ($30 to $100) will generate an additional $4,200 in application fees. FY 21-22: The fee increase will continue to generate an additional $4,200 in application fees. Fl’ 22-23: The fee increase ($100 to $110) will generate an additional $600 in application fees. Fl’ 23-24: The fee increase will continue to generate an additional $600 in application fees. Fl’ 24-25: The fee increase ($110 to $120) will generate an additional $600 in application fees.

I FY 25-26: The fee increase will continue to generate an additional $600 in application fees.

600 Temporary Training License or Graduate Training Certificate

Fl’ 20-21: The fee increase ($30 to $115) will generate an additional $51,000 in application fees. Fl’ 21-22: The fee increase will continue to generate an additional $51,000 in application fees. Fl’ 22-23: The fee increase ($115 to 5125) will generate an additional $6,000 in application fees. Fl’ 23-24: The fee increase will continue to generate an additional $6,000 in application fees. FY 24-25: The fee increase ($125 to $140) will generate an additional $9,000 in application fees.

II FY 25-26: The fee increase will continue to generate an additional S9,000 in application fees.

500 Physician Assistants

Fl’ 20-21: The fee increase (530 to SilS) will generate an additional 542,500 in application fees. fl 21-22: The fee increase will continue to generate an additional $42,500 in application fees. Fl’ 22-23: The fee increase ($115 to $125) will generate an additional $5,000 in application fees. FY 23-24: The fee increase will continue to generate an additional $5,000 in application fees. FY 24-25: The fee increase ($125 to $140) will generate an additional $7,500 in application fees. FY 25-26: The fee increase will continue to generate an additional $7,500 in application fees.

51 Supervisin2 Physicians

Fl’ 20-2 1: The fee increase ($95 to $145) will generate an additional $2,550 in application fees. FY 21-22: The fee increase will continue to generate an additional $2,550 in application fees. Fl’ 22-23: The fee increase (5145 to $160) will generate an additional S765 in application fees. FY 23-24: The fee increase will continue to generate an additional $765 in application fees. Fl’ 24-25: The fee increase ($160 to $175) will generate a” additional $765 in application fees. FY 25-26: The fee increase will continue to generate an additional $765 in application fees.

13 Acupuncturists and Physician Acupuncturists

FY 20-21: The fee increase ($30 to $100) will generate an additional $910 in application fees. FY 21-22: The fee increase will continue to generate an additional $910 in application fees. FY 22-23: The fee increase ($100 to $110) will generate an additional $130 in application fees. FY 23-24: The fee increase will continue to generate an additional $130 in application fees. FY 24-25: The fee increase ($110 to $120) will generate an additional $130 in application fees. Fl’ 25-26: The fee increase will continue to generate an additional $130 in application fees.

50 Respiratory Therapists

FY 20-21: T lie fee increase (53(1to $100) will generate an additional 53,500 in application fees. Fl’ 21-22: The fee increase will continue to generate an additional 53,500 in application fees. Fl’ 22-23: The fee increase ($100 to $110) will generate an additional $500 in application fees. FY 23-24: The fee increase will continue to generate an additional $500 in application fees. Fl’ 24-25: Tb e fee increase ($110 to $120) will generate an additional $500 in application fees. Fl’ 25-26: The fee increase will continue to generate an additional $500 in application fees.

80 Athletic Trainers

FY 2(1-2I: The fee increase ($20 to $100) will generate an additional $6,400 in application fees. FY 21-22: The fee increase will continue to generate an additional $6,400 in application fees. Fl’ 22-23: The fee increase (5100 to $110) will generate an additional $800 in application fees. Fl’ 23-24: The fee increase will continue to generate an additional $800 in application fees. Fl’ 24-25: The fee increase ($110 to $120) will generate all additional $800 in application fees. FY 25-26: The fee increase will continue to generate an additional $800 in application fees.

12 10 Perfusionists

Fl 20-21: The fee increase ($50 to $120) will generate an additional $700 iii application fees. Fl 21-22: The fee increase will continue to generate an additional $700 in application fees. Fl 22-23: The fee increase ($120 to $130) will generate an additional $100 in application fees. Fl 23-24: The fee increase will continue to generate an additional $100 in application fees. Fl 24-25: The fee increase ($130 to $145) will generate an additional $150 in application fees. Fl 25-26: The fee increase will continue to generate an additional $150 in application fees.

5 Perfusionist Reactivation Fee

Fl 20-21: The fee increase ($50 to $105) will generate an additional $275 in application fees. Fl 21-22: The fee increase will continue to generate an additional $275 in application fees. Fl 22-23: The fee increase ($105 to SI 15) will generate an additional $50 in application fees. Fl 23-24: The fee increase will continue to generate an additional $50 in application fees. Fl 24-25: The fee increase ($115 to $125) will generate an additional $50 in application fees. Fl 25-26: The fee increase will continue to generate an additional $50 in application fees.

I Temporary Graduate Perfusionist

Fl 20-21: The fee increase ($50 to $120) will generate an additional $70 in application fees. Fl 21-22: The fee increase will continue to generate an additional $70 in application fees. Fl 22-23: The fee increase ($120 to $130) will generate an additional $10 in application fees. Fl 23-24: The fee increase will continue to generate an additional $10 in application fees. Fl 24-25: The fee increase ($130 to $145) will generate an additional $15 in application fees. Fl 25-26: The fee increase will continue to generate an additional $15 in application fees.

3 Temporary Provisional Perfusionist

Fl 20-21: The fee increase ($41)to $80) will generate an additional $100 in application fees. Fl 21-22: The fee increase will continue to generate an additional $100 in application fees. Fl 22-23: The fee increase ($80 to $88) will generate an additional $20 in application fees. Fl 23-24: The fee increase will continue to generate an additional $20 in application fees. Fl’ 24-25: The fee increase ($88 to $95) will generate an additional $18 in application fees. Fl 25-26: The fee increase will continue to generate an additional $18 in application fees.

10 Genetic Counselors

Fl 20-2 1: The fee increase ($50 to $120) will generate an additional $700 in application fees. Fl 21-22: The fee increase will continue to generate an additional $700 in application fees. Fl 22-23: The fee increase ($120 to $130) will generate an additional $100 in application fees. Fl 23-24: The fee increase will continue to generate an additional $100 in application fees. Fl 24-25: The fee increase ($130 to $145) will generate an additional $150 in application fees. Fl 25-26: The fee increase will continue to generate an additional $150 in application fees.

5 Genetic Counselor Reactivations

Fl 20-21: The fee increase ($50 to $105) ivill generate an additional $275 in application fees.

13 FY 21-22: The fee increase will continue to generate an additional $275 in application fees. Fl’ 22-23: The fee increase ($105 to SI 15) will generate an additional $50 in application fees. Fl’ 23-24: The fee increase will continue to generate an additional $50 in application fees. FY 24-25: The fee increase ($115 to $125) will generate an additional S50 in application fees. FY 25-26: The fee increase will continue to generate an additional S50 in application fees.

15 Temporary Provisional Genetic Counselors

FY 20-21: The fee increase ($50 to $90) will generate an additional $600 in application fees. FY 21-22: The fee increase will continue to generate an additional $600 in application fees. Fl’ 22-23: The fee increase ($90 to $100) will generate an additional $150 in application fees. FY 23-24: The fee increase will continue to generate an additional $150 in application fees. Fl’ 24-25: The fee increase ($100 to $105) will generate an additional $75 in application fees. Fl’ 25-26: The fee increase will continue to generate an additional $75 in application fees.

Total Economic Impact to Applicants

Based upon the above application fee increases, the total economic impact per fiscal year is as follows:

Fl’ 20-21: $263,780 FY 21-22: $263,780 FY 22-23: $32,275 Fl’ 23-24: $32,275

Fl’ 24-25: $43,806 Fl’ 25-26: $43,806 Total: $679,722

BIENNIAL RENEWAL FEES

Approximately 12,721 licensees will be impacted by the graduated biennial fee structure.

9,009 Osteopathic Physicians

Fl’ 20-21: The fee increase ($220 to $330) will generate an additional $990,990 in revenue. FY 22-23: The fee increase ($330 to $420) will generate an additional $810,810 in revenue. Fl’ 24-25: The fee increase ($420 to $450) will generate an additional $270,270 in revenue.

2,603 Physician Assistants

Fl’ 20-21: The fee increase ($10 to $40) will generate an additional $78,090 in revenue. Fl’ 22-23: The fee increase ($40 to $75) will generate an additional $91,105 in revenue. Fl’ 24-25: The fee increase ($75 to $80) will generate an additional $13,015 in revenue.

159 Acupuncturists and Physician Acupuncturists

Fl’ 20-21: The fee increase ($25 to $40) will generate an additional $2,385 in revenue.

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the or Board’s mandate to protect the health, safety and welfare of the public is carried out. The new fee structure for application fees is beneficial for licensees generally as the costs associated with each application will be paid by the applicant rather than distributed among the Board’s licensees. Additionally, the Board’s graduated fee approach is beneficial because the application fee increases are reflective of actual costs during each biennium and biennial renewal fees coincide more closely with the projected expenses for each biennium.

(1$) Explain how the benefits of the regulation outweigh any cost and adverse effects.

The Board is a statutorily created board which has powers and duties set forth in the act, including power to: determine qualifications and fitness of applicants; adopt and revise regulations; refuse, revoke or suspend licensees; establish fees for the operation of the board; and conduct hearings. The Board’s expenses include: Bureau administration, Commissioner’s and Revenue office services, Departmental services, legal office services, hearing expenses, enforcement and investigation costs, Professional Compliance Office costs, board member expenses and Professional Health Monitoring Programs (PHMP) costs. Under section 13.1(a) of the act, the Board is required to support its operations from the revenue it generates from fees, fines and civil penalties. If the revenues raised by fees, fines and civil penalties imposed under this act are insufficient to meet expenditures over a two-year period, the board must increase those fees by regulation so that the projected revenues will meet or exceed projected expenditures.

The rulemaking would benefit every citizen of the Commonwealth in that it would ensure the fiscal integrity of the Board and allow the Board to carry out its mission. The costs to applicants and licensees are outweighed by the Board’s duty to license and regulate the practice of osteopathic medicine in the public interest. Additionally, application fees will more accurately address the actual cost of resources devoted to processing applications.

(19) Provide a specific estimate of the costs and/or savings to the regulated community associated with compliance, including any legal, accounting or consulting procedures which may be required. Explain how the dollar estimates were derived.

As reflected in the Board’s response to question 17, the regulated community will incur additional costs as a result of the graduated application and biennial renewal fee increases. By adding the costs for the graduated application fees with biennial renewal fees per fiscal year, the Board estimates that the cost to licensees and applicants is as follows: FY 2020-2021 at $1,350,108; FY 202 1-2022 at $263,780; FY 2022-2023 at $955,620; FY 2023-2024 at $32,275; FY 2024-2025 at $332,636 and FY 2025-2026 at $43,806. The Board does not anticipate additional administrative, legal, accounting or consulting costs to the Board, applicants or licensees by implementing the rulemaking. The regulatory amendment will permit the Board to continue to fund the costs of its operations. There are no other costs or savings to state government associated with compliance with the rulemaking.

(20) Provide a specific estimate of the costs and/or savings to the local governments associated with compliance, including any legal. accounting or consulting procedures which may be required. Explain how the dollar estimates were derived.

There are no costs or savings to local governments associated with compliance with the

16 rulemaking.

(21) Provide a specific estimate of the costs and/or savings to the state government associated with the implementation of the regulation, including any legal, accounting, or consulting procedures which may be required. Explain how the dollar estimates were derived.

The Board will incur a rniiiimal cost to revise its print and online application forms and online renewal platform to indicate the increased fees. The Board would incur no other increase in administrative costs by implementing the rulemaking. There are 110 other costs or savings to state government associated with implementation of the rulemaking.

(22) For each of the groups and entities identified in items (19)-(21) above, submit a statement of legal, accounting or consulting procedures and additional reporting, recordkeeping or other paperwork, including copies of forms or reports, which will be required for implementation of the regulation and an explanation of measures which have been taken to minimize these requirements.

This rulemaking will not require any additional record keeping nor will there be any legal, accounting or consultiiig procedures required for implementation of the rulemaking. The new fees will require iio additional paperwork, as these fees are being imposed to cover the Board’s costs associated with services that are already being provided and paperwork that is already required.

(22a) Are forms required for implementation of the regulation? Yes, the Board will have to revise its print and online application forms and online renewal platform to indicate the increased fees.

(22b) If forms are required for implementation of the regulation, attach copies of the forms here. If your agency uses electronic fornm, provide links to each form or a detailed description of the inlbrmation required to be reported.

In October of 2016, the Bureau launched the Pennsylvania Licensing System (PALS), which provides for an online application and biennial renewal system. Most of the Board’s applications and biennial renewals are in PALS. As reflected in Attachment “B,” the only remaining hard copy forms are reactivations and application forms for supervising physicians. Regarding all the other initial applications, because the Board no longer uses paper applications, the Board is providing online “checklists” that correlate with each application. For biennial renewals, the Board has attached copies of biennial renewal forms that are reflective of the online content of the online content.

(23) In the table below, provide an estimate of the fiscal savings and costs associated with implementation and compliance for the regulated community, local government, and state government for the current year and five subsequent years.

Current FY FY +1 FY +2 FY +3 FY +4 FY +5 Year (19-20) Year Year Year Year Year (20-21) (21-22) (22-23) (23-24) (24-25) SAVINGS: SO SO $0 SO SO SO

Regulated SO $0 SO $0 SO $0

17 Community Local Government State Government Total SO SO SO SO SO SO Savings COSTS: SO SO SO SO 50 SO

Regulated $1) $1,350,108 $263,780 $955,621) $32,275 $332,636 Community Local Government State Government Total Costs SO $1,350,180 $263,780 $955,620 $32,275 $332,636 REVENUE LOSSES: Regulated SO $0 Coinmunitv Local Government State Government Total SO SO N/A N/A N/A N/A Revenue Losses

(23a) Provide the past three-year expenditure history for programs affected by the regulation.

Program Fl’ - 3 Fl’ - 2 Fl’ -1 Current Fl’ 16-17 17-18 18-19 19-20 (Actual) (Actual) (Projected) (Projected) State Board $1,554,198.23 $1,667,045.13 $1,935,000 $2,015,000 of Osteopathic Medicine

(24) For any regulation that may have an adverse impact on small businesses (as defined in Section 3 of the Regulatory Review Act, Act 76 of 2012), provide an economic impact statement that includes the fbllowing:

(a) An identification and estimate of the number ofsmall businesses subject to the regulation. (b) The projected reporting. recordkeeping and other administrative costs required for compliance with the proposed regulation, including the type of professional skills necessary Forpreparation of the report or record. (c) A statement of probable effect on impacted small businesses.

I8 (d) A description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation.

(a) All “small businesses” as that term is defined by the Regulatory Review Act and the SBA, that employ licensees would be subject to the rulemaking. The Board does not collect data relating to the size of the businesses that employ its licensees. Please also see the response to Question 15.

(b) There are no projected reporting or recordkeeping costs required for compliance. There are only negligible additional administrative costs required to revise online applications for increased fees.

(c) The probable effect on impacted small businesses may be an increase in application and biennial renewal fees for applicants or licensees employed by small businesses, should the businesses choose to pay these fees for employees.

(d) The Board has evaluated and considered increasing fees since 2016. As previously discussed, the Board’s expenditures exceed its revenue. Section 13.1(a) of the act mandates a fee increase when expenditures outpace revenue. Thus, based upon the insufficient revenue and continued reduction of remaining funds, the Board determined that fee increases are the only way to sustain operations, insuring public health and safety.

(25) List any special provisions which have been developed to meet the particular needs of affected groups or persons including, but not limited to, minorities, the elderly, small businesses, and farniers.

No groups with particular needs have been identified.

(26) Include a description of any alternative regulatory provisions which have been considered and rejected and a statement that the least burdensome acceptable alternative has been selected.

The Board considers the regulations to be the least burdensome and acceptable alternative, consistent with public health, safety and welfare. This increase is necessary to ensure the fiscal integrity of the Board and to assure that the Board’s mandate to protect the health, safety and welfare of the public is carried out The new fee structure for application fees is beneficial for licensees generally as the costs associated with each application will be paid by the applicant rather than distributed among the Board’s licensees. The Board considered an alternative fee increase that did not include a graduated fee schedule. The Board believes the graduated application fee and biennial renewal fee increases are beneficial because the application fee increases are reflective of actual costs to process applications and biennial renewal fees coincide more closely with the projected expenses for each biennium. Additionally, after the proposed rulemaking, the Board asked BFO to review and update fiscal revenue and expenditures. BFO found that, in addition to increases in the revenue and licensee count, expenses incurred by the Board during the pandemic have decreased. ‘hile fee increases are still needed prior to the next renewal period for the Board to remain solvent, the Board was able to decrease the renewal fees for physicians to ease the burden. As reflected in Annex A, the biennial renewal fees for osteopathic physicians were adjusted down from $351)to $330 in the November 1,2020—October 31, 2022 biennial renewal period; from $425 to $420 in the November 1, 2022—October 31, 2024 biennial renewal period; from $475 to $450 in the November I, 2024—October 31, 2026 biennial

19 renewal period.

(27) In conducting a regulatory flexibility analysis. explain whether regulatory methods were considered that will minimize any adverse impact on small businesses (as defined in Section 3 of the Regulatory Review Act, Act 76 of 2012). including:

a) The establishment of less stringent compliance or reporting rcquirements for small businesses; b) The establishment of less stringent schedules or deadlines for compliance or reporting requirements for small businesses; c) The consolidation or simplification of compliance or reporting requirements for small businesses; d) The establishment of performance standards for small businesses to replace design or operational standards required in the regulation; and e) The exemption of small businesses from all or any part of the requirements contained in the regulation.

a) & b) All applicants pay the application fees at the time the application is submitted, and all licenses renew biennially. The Board did not consider less stringent reporting requirements or deadlines for small businesses or for licensees who work for small businesses.

c) There are no compliance or reporting requirements that could be consolidated or simplified. The application and biennial renewal processes are the same whether a particular licensee or applicant is, or is employed by, a small business or a large business.

d) The regulations do not contain design or operational standards that need to be altered for small businesses.

e) To exclude any applicants or licensees from the requirements contained in the rulemaking based on the size of the business would not be consistent with public health and welfare because it would prevent the Board from obtaining adequate revenue to meet projected expenditures and it would not be able to carry out its legislative mandate.

(28) If data is the basis for this regulation, please provide a description of the data, explain in detail how the data was obtained, and how it meets the acceptability standard for empirical, replicable and testable data that is supported by documentation, statistics, reports, studies or research. Please submit data or supporting materials with the regulatory package. lithe material exceeds 50 pages, please provide it in a searchable electronic format or provide a list of citations and internet links that, where possible, can be accessed in a searchable format in lieu of the actual material. Ifother data was considered but not used, please explain why that data was determined not to be acceptable.

The Board relied on data contained in the Bureau’s executive report on the Review’ of State Professional and Occupational Licensure Board Requirements and Processes. The report can be found at: l1ttps://www.dos.pa.oJProfessionalLicensin/Documents/EO2O 17-03—Executive—Report— Occupational-Licensingpdf

20 The Board relied on data contained in the U.S. Osteopathic Licensure Summary by American Osteopathic Association (September 2019). (See, Attachment “C”). The Board also relied on financial records of the Board presented by BFO, including the BFO Financial Report and fee report forms that provide the breakdown of costs for application fees. (See, Attachment “D”)

(29) Include a schedule for review of the regulation including:

A. The length of the public comment period: 30 days from publication in the PA Bulletin

B. The date or dates on which any public meetings or hearings will be held: The proposed rulemakiii was discussed at public Board meetings in Aueust 10, 2016 August 9. 2017. February 14, 2018, April 11. 2018. August 22. 2018, October 24, 2018, February 13. 2019, August 14. 2019. and December 11. 2019. On June 10. 2020, the Board, after publication of the proposed rulemaking, reviewed all comments and adopted the final rulemaking.

C. The expected date of delivery of the final-form regulation: Summer 2020

D. The expected effective date of the final-form regulation: Summer 2020

B. The expected date by which compliance with the final-form Upon publication in the regulation will be required: PA Bulletin as final.

F. The expected date by which required permits, licenses or other N/A approvals must be obtained:

(30) Describe the plan developed for evaluating the continuing effectiveness of the regulations after its implementation.

The Board regularly evaluates the effectiveness of its regulations. Additionally, the Board regularly reviews requests by licensees and members of the public to amend its regulations causing the Board to evaluate the regulations’ impact and necessity. The Board reviews all regulatory proposals at regularly scheduled meetings. The Board is scheduled to meet on the following dates in 2020: August 12, October 14 and December 9, 2020.

2t Attachment A

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Work: Malvem,

325

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Matt

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Zackary

Psychiatry

[email protected]

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Dr.

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langenauverizon.net Christine

Bhargav

Nancy

nbaxi4aim.com

[email protected] 3742

irrehel

259 David

(717) Harrisburg,

333

Indcpendent

Harry

David

House

6A-5334

Chris

Central

North

Wright

Crisswell

Market

Callahan

570.892.1570

Line

State

610-644-6755

783-5417

Rcadshaw,

Baxter,

Byard

Pa.

Black.Langenau

Burritt

Hickemell, Representatives

irrc.state.;

Washington

Andres,

Gastroenterology

Resident

Route —

Ave.,

Center

Street

19355

Fees

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Road

M.D.

17101

DO.

Suite

257

Minority

D.O.

for

14th

PCI Franklin,

aus

Majority

Cell:

Seneca,

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Avenue

200

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Review

D.O.

610-996-5705

Chair

Associates

Chair

Scranton,

Commission

16323

16346

Health

COMMENTERS

(Home)

(Andrea-Bush

18503

Internal Medicine) 16A-5334 — Fees

Leah Campbell, D.O. Elk \‘alley Medical Center Saint Vincent Medical Group Allegheny Health Network Tel 814-774-3128 Leah.CampbeIIahn.org

Richard W. Conron, Jr., DO FACS rickconrongmail.com

Darlene Dunay, D.O. [email protected]

Maria Demario, DO. Mdemariogatewaydoetors.eom

Marianne Dombrowski, DO mdombrowski7yahoo.com

Elena Farrell, D.O. 4311 Secretariat St. Harrisburg,PA 17112 eyedoc1959gmail.com

Wayne Fellows, D.O. doctorfellowsgmail.com

Eric 3. Fels. DO. ejf529gmail.com

S. Gordon D.O. [email protected]

Lee J. Guo, D.O. [email protected]

Allan C. Johnson Jr., D.O., C.P.E. Medical Director, Ambulatory Clinical Informatics Medical Director, Saint Vincent Urgent Care Allegheny Health Network F’:814-452-5384 C: 814-746-1473 Al1aniohnson2ahn.org

Ken Jusko, D.O. kjusko13gmall.com jonpaIygmafl.com robertsl Justin phamnh89grnai1.corn Nam Jonathan Dr. [email protected] [email protected] ANN Dhimitd dana.mincergmai1.com Emergency 858-531-5090 Dana sherimecollumgmail.com 215-947-8701 Huntingdon 1 Comprchcnsive Suite 727 Rheumatologist [email protected] Sherilyn Michael mmatEapsyeh-med,com [email protected] Now (724) 2616 CEO Diplomate Mark Diplomate Dr. 6A-5334 Craig Welsh Joseph Pham, SVH/WMH Roberts. 201 L. Castle, Wilmington of 652-2323 Matta, 8032gmail.com Mincer, Psych-Med Nikolla, McCollum, Paly, L. Oser — Road Physician of 0.0. of Tittermary Lamantia Valley, PA Fees D.O. the the 0.0. 0.0. Arthritis 0.0 0.0. 16105 American American Road PA Associates 0.0. McCollum, 19006 Care Board College Consultants of DO. of Psychiatry’ Osteopathic & Neurology Family Practioners 16A-5334—Fees

Christopher B. Rogers, DO. FACC (484)706-3010 [email protected]

TroyTrayer, D.O. trayerdogmai1.com

Chedse Vellozo [email protected]

Richard L Weinberger, D.O., FACOI FACP dchardlweinbergergmail.com

Lynn M. Wilson, D.O. [email protected]

Andy Sandusky Executive Vice President, Public Policy and Association Affairs PA Osteopathic Medical Association (PUMA) Executive Director PA Osteopathic Family Physicians Society (POFPS) 1330 Eisenhower Blvd. Kanisburg,PA 17111 Phone: 717-939-9318 ext. Ill Cell: 717-727-3668 asanduskypomu,org

Michael D. 1.Siget, J.D., M.P.A. Legislative and Regulatory Counsel PA Medical Society (PAMED) 77 East Park Drive P.O. Box 8820 Harrisburg, PA 17105 855-726-3348 717-558-7750 msigetpamedsoc.org Attachment B (Part 1) PHYSICIAN AND SURGEON Page1of 2

Evaluationresults: Board/Commission:OsteopathicMedicine License Types OsteopathicPhysicianand Surgeon Obtained By: Application (9o CheckList Name Instnctions j I’

. Pleasefollowall directions.Anydisciepancieiwill cause a delay inthe issuanceof a license. If thisapplicationishot completedwithin sixmonths,, Application ‘spdatesof certainsectionsandsupportingdocumentswill berequired,You maynot practice intheCommonwealthofPennsylvaniauntilyou havebeen issueda license. Anappllcafion.feèof4Sis required.Pleasenotethat all fres arenon A U ° I reindable $flaoo -

• Allhealth-relatedlicensees/certificateholdersandfimeraldirectorsare considered“mandatoryreporters”undersection6311of the ChildProtective ServicesLaw (23 P.S. §6311).Therefore,allpersonsapplyingfor issuance of aninitial licenseor certificatefromanyof the health-relatedboards (exceptthe State Boardof VeterinaryMedicine)or from the StateBoardof FuneralDirectorsarerequiredto complete,as a conditionof licensure,3 Child Abuse CE hoursof approvedtrainingby theDeparthieñtof ThimanServicesWITS)on thetopicof child abuserccogiilffonandreporting..After yrnihave completed therequiredcourse,theapprovedproviderwill electronicallysubmityour

• name,date of attendance,cit. to theBureau.For that reason, ft is imperative thatyou registerfor Sc courseusingthe informhfionprovidedon your

• applicationfor licenaure/certiflcailon.Alistof OHS-approvedchildabuse educationproviderscanbe foundonthePepartmeiflof StateWebsite. Cdmlnd History Ezovldea recent CriminalHistoryRecordsCheek(CHRC)fromthestale check policeor other state agencythat is the officialrepository for criminal history record information foreverystateIn whichyou have live4 worked, orcompletedpmfessionalfraining/studiesThrthepastten (10) yeañ. The report(s)must be datedwithin90 daysofthe date the applicationis submitted.For applicanfsliving,working,or completingtraining/sthdiesin Pennsylvania,you CHRCrequestwillbeautomaticallythibmittedtothe PennsylvaniaStatePoliceupon submissionof this application.ThePATCH feewillbe includedat checkout.YourPA CJifiC willbe sentdirectlyta the oard/Coppnjssioii. Yoqwillbejiotiicd if ø4djfionalaction is requkcd.For individualsliving,working,orcompletingtraining/studiesoutsideof ‘ennaylvaniadiningthepast ten (10)years,in lieu of obtainingindividual statebackgrotmd.checks)youmayelectto provideBOTHa stateCI4RCfroix thestatein whichyou ctñrentlyreside,ANDyour FBIIdentityHistory $nmmcnyCheck,availableat https:Uwww.fbLiov/servic&cjisIidentjiy histon’-summary-checks.

Pleasenote: For applicantscurrentlyliving,working,ci ôompleflng. training/studiesin California,Arizona,orOhio:Dueto the laws ofthese states,the Board is notan eligiblerecipientof CHRC’sor yourCHRCwill notbe issuedto you foruploadto theBoard,PleaseobtainyourFedeml

https//www.paltpa.gov/ 10/25(2019 Pae2of2

CheckList Namej Imatnicions —— IlBurMuof Investigation(FBI)Identityhistory SummpryCheck, availableat linknotedabove. [Aséffqueiy disclosurereportfromtheNationalPractitionerData Banic I CIO (NPDB)is required. ‘Verificationof AOAApprovedInternshipFormmustbe received Graduate Training DIRECTLYfromthehospitalwhereyouhave completedyour firstyear of

Contactthelicensingauthoritiesof thestates,territoriesor countrieswhere youhold or have everhelda license,certificate,permit,registrationor other . authorizationto practicea health-relatedprofession(whetheractive,inactive, Letter of Good expiredor current)andrequcit lettersof goodstanding/verificationof Standing (LOGS) ilcensurein that stale oriurisdiction.Th lettermustincludethe following: licenseissueand expirationdate,licensestatus(currentor expired)and ‘disciplinarystanding.The letter(s) of good standing piust be sent directly to the Board. INational NationalBoardscores(NBOME/COMLEX)mustbe receivedDrRECUY jamlnaflou fromthe NationalBoardof OsteopathicMedicalExaminers,Inc. Section9.1(a) of ABC-MAP requiresthat all prescribersor dispensers,as definedin Section3 of ABC’MAP,applying.forlicensurcfapovai complete

•at least4 hoursof Board-approvededucationconsistjngof 2 hoursinpain . managementor the idenfifcationof addictionand2 hoursin the practicesof

. prescribingor dispensingof opioids.Applicantsseekinglicensure/approval on or afterJuly I, 2017,mustdocument,withinoneyear from issuanceof the

. licensthe/approval,thatthey completedthis educationeitheras part of an initialeducationprogram,a stand-alonecoursefroma Board-approved courseprovider, or a continuingeducationcoursefroman approved Oploid c continuingeducationprovider.The4 hbursof Board-approvededucation . needsto be completedonlyonce.SeetheBoard’swtbsite thr the Opiold

I EducationFormsandadditionaliçlbrnrnflon.

‘The AchievingBetterCarebyMonitoñngMlPrescriptionsProgramAct (ABC-MAP)(Act 191of 2014,as amended)isai’ailableon the Legislature’s ebsite at http://wvJeujs.state.p&uafcfdocsILejis/UJuconsCheck.cftui7

. xfl\ne=HTM&vr2014&sesslnd=O&smthLwlnd=O&act=191

TheBold’s Regulationsaxeivailableonthe Boakil’swebsite.

OsteopathicManipulationTest(01Sf) ores mustbekeceivedDIRECTLY eunsylvan a ci frdm the testingservice. Record of frenflcation f MedicalEducationmustbereceivedDWFCUY fromthe Graduation medicalschool. CurriculumVitaelistingALL periodsof employmentor unemployment(i.e., RnumejCurriculum childrearing,reseaah, etc.)fromgraduationfrommedicalschooltopresent. Vitae The list mustbe in chronologicalorder,includethemoäthandyear,and I______indicatethe state/territoryin whichtheçmploymentoccurred.

https://www.pals:pa.gov/ 10fl5fl019 rage I of2

Evaluaffonresults: - floard!Commission:OsteopathicMedicine License Type: QsteopathicPhysicianand Surgeon Obtained By: Application oa CheckList Name Instructions

. Pleasefbllowall irections. Anydiscrepancieswill causea delayin the’ • issuanceof a license. if thisapplicationis hot completedwithinabcmonths, Application updateáo certainsectionsand supportingdocumentswill be requhtd. You maynotpracticein’theCommonwealthof Pennsylvaniauntilyou havebeen issued.alicense. IAnapplicationtee of 4t16is required.Pleasenote that all fees non IA ca on FCe an r frefimdable. 45.3O Mi health-relatedlicenseeslcerlificateholdersand funeraldirectorsare — considered“mandatoryreporters”undersection6311of the ChildProtective Serv!cbsLaw (23P.S. §6311).Therefore1all personsapplyingfor issuance (exceptof aninitiallicenseor certificatefromanyof the health-relatedboards the StateBoardofVetetinaryMedie5ze)or fromthe StateBoardof FuneralDirectorsarerequiredto complete,as a conditionof Jicensure,3 Child Abuse CE bows of approvedtrainingby the Deparuhentof HumanServices(1)145)on the topicof childabuserecognitionandreporting.Afteryou have completed therequiredcourse,theapprovedproviderwill electronicallysubmityour namejdate,of attendance,etc.to theBureau.For that reason,it is imperative thatyou registerfor Se courseusingtheinformationprovidedon your applicationfor licensurWcertiflcafion.A listof DHS-appmvedchildabuse

. educationproviderscan be foundontheDepartmeDtof StateWebsite. Criminal History Providea recentCriminalHistoryRecordsCheck(CHRC)fromthe state Check police or otherstateagencythat Isthe officialrepository forcriminni history record information for everystatein whichyouhave lived,worked, or completedprofessionaltraining/studiesforthepastten (10)years.The report(s)mustbe datedwithin90 daysof the datethe applicationis &ubmited.For applicantslivilig,working,or completingtmlnlng/stbdiesin Pennsylvania,yoth CIiliC requestwillbe automaticallysubmittedtothe PennsylvaniaStatePoliceuponsubmissionof this applicaffeaThe PAT.CH feewillbe includedat checkout.YourPA CEtC willbe sentdirectlytothe Board/Commission.Yu willbe notifiedif add)tionalactionis requjxccLFor individualsliving,working,or completingtraining/studiesoutsideof Pennsylvaniaduringthepastten (10)years,in lieu ofobtainingindividual statebackgroundchecks,youmay electto provideBOTh a state CHRCfrom the statein whichyou ctrrenfiyreside,ANDyour FBIIdentityHistory SummaryCheck,availableat httpsWwww.ibLuov/serviccs/cj•is/jdentjy_ history-summary-checks.

Pleasenote;ior applicantscurrentlyliving,working,or completing airilng/studies in California,Arizona,or Ohio:Duetothe lawsof these states,the Boardis not an eligiblerecipientof CHRC’sor yourCHRCwill not beissuedto you for uploadto theBoird.Please obtainyourFederal

https:/fwww.paltpa.gov/ 10/25/2019 Page 2of2

Checklist Name Instriwtions

.: Bureauof Investigation(FBI)IdentityHistorySnmaay Check,available at ‘ . thelink notedabove. A selfquerydisclosurereportfrom theNationalPractitionerData Bank Databank . (NPDB)is required. Verificationof AOAApprovedInternshipFormmustbe received Graduate Training DIRECTLYfromthehosjiitalwhereyou havecompletedyour first year of training. Contactthelicensingauihoridesof thestates,territoriesor counties where - you holdor haveeverheld a license,certificate,permit,registrationor other . authorizationtopracticea health-rd tedprofession(whetheractive,inactive, Letter of Good expiredor current)andrequestlettersof goodstan±ng/vaiflcation of Standing (LOGS) licensurein that stateorjurisdiction.Thelettermustincludethe following: licenseissueand expirationdate, licensestatus(currentor expired)and disciplinaiystanding,The letter(s) of good standing piust be sent flrectIy

, to the fleard.

. Nadonal Boardscores(NBO?vE/COMLEX)mustbereceivedDIRECTLY 1NnjftgU fromthe NationalBoardof OsteopathicMedicalExaminers,Inc.

. Section‘9.1(a)of ABC-MAP requiresThatallprescribersor dispensers,as . - definedin Section3 ofABC’MAP, pplying forlicensure/appiovalcomplete

• at least4 hoursof Board-approvededucationconsistingof 2 hoursinpain managementor theidentificationof addictionand2 hoursinthepractices of . prescribingor dispensingof opioids.Applicantsseekinglicensure/approval on orafler July 1,2017,must document,withinbiieyearfromissuanceof the flceñsure/approval,thatthey completedthis educationeitheras part of an initialeducationprogram,a stand-alonecoursefroma Board-approved courseprovider, or a continuingeducationcoursefroman approved Oploid continuingeducationiirovider.The 4 hoursoffloard-ajproved education needstobe completedonlyonce. Seethe Board’swebsiteforthe Opiold . EducationFormsandadditionalluformation.

. The AchievingBetterCareby MonitoñngMlPrescriptionsProgramAct (ABC-MAI (Act 19l,of 2014,as amended)isá’ailableontheLeglélature’s websiteat: http://ww’.1euiss1ate.pa..us/cfdocsILeiWlJ/ucohsChecJccfin? ixtfvpeHtM&vr2014&sesslndO&smthtwlnd=8&act=J 91

• TheBbikd’sRegulationsare a’aliable on theBoaid’iwebsita

OsteopathicManipulationTest (OMT)scorcsmustbereceivedDIRECTLY FtflflSYIVanb Exam fromthe testingservice. Record of NVerificaffonof MedicalEducationmust be receivedDIRECTLYfrom the Graduation Jmedical school. CurriculumVitaelistingALL periodsof employmentor unemployment(i.e., Resume/Curriculum child rearing,research,etc.) from graduationfrommedicalschoolto present Vitae The listniustbein chronologicalorder,includethemonthandyear, and

• indicate th state/territoryin whichtheemploymentoccurred.

,https:llwvrw.pals.pa.govl . 10/25/2019 Page 1 of2

Evaluationresults: BoardlCommissian: OsteopathicMedicine LicenseType: OsteopathicPhysicianandSurgeon Obtained By: Application

CheckListName Instructions f N PleasefollDwall directions.My discrepancieswill causea delayin the

• issuanceof a license. If thisapplicationis not completedwithinsix months, Application updatesof certainsectionsand supporthg documentswill be.required. You

• may notpracticeinthe Commonwealthof Pennsylvaniauntilyou have been Issueda license. L . JIMapplicationfeeof $4tJ is required;Pleasenotethat all fits are non rbafbn Fee Jfremndable. $oS co 411health-relatedlicensees/certificateholdersandfimeraldirectorsare considered‘mandatoiyreporters”undersection6311of theChildProtective ServicesLaw(23P.S. §6311).Therefore,allpersonsapplyingfor issuance of an initiallicenseor certificatefrom anyof the health-relatedboards (exceptthe StateBoardof VeterinaryMedicine)or fromthe StateBoardof ‘ FuneralDirectorsare reqUiredto complete, as a conditionof Iicensure,3 Child Abuse CE hoursof approvedtrainingbythe Departmentof HumanServices(DHS)on

• the topic of childabuserecognitionsndreporting.Afteryouhave completed the requiredcourse,theapprovedproviderWI]! electionicailysubmityour name, dateof attendance,etc.to the Bureau.For thatreason,itis imperative thatyouregisterforthecourseusingthe informationprovidedon your applicationforlicensu&ceftiflcafion.A list of DHS-approvedchildabuse educationproviderscanbe foundonthe Departuentof StateWebsite. Criminal History Providea recentCriminalHistoryRecordsCbeck(CIIItC)from the slate Check policeor otherstateagencythat is the officialrepositoryfor criminal history record information for every state in whichyouhavelived,worked, or completedprofrssionaltraining/studiesfor thepastten(10)years.The report(s)mustbe datedwithin90 daysof the datetheapplicationis submitted.Forapplicantsliving,working,br completingtraining/studiesin Pennsylvania,yourCHRCrequestwill be automaticallysubmittedto the PennsylvaniaStatePoliceuponsubmissionof thisapplication.The PATCH. fee willbe includedat cbeckout YourPA CHRCwillbesentdirectlyto the Board/Commission.Youwillbe notifiedif a4djtiqnalactionisrequired.For individualsliving,working,or completingtraining/studiesoutsideof Pennsylvaniaduringthe jiastten (10)years,in lieuofobtainingindividual statebackgroundchecks,you may elect to provideBOTHa stateCHRCfrom the statein whichyou currentlyreside,ANDyourFBIIdentityHistory SummaryCheck,availableathttns:1/wwwibLuov/services/cjiwidentiiv_ history-summary-checks.

Please note: Forapplicantscurrentlyliving,woiking,or completing training/studiesin California,Arizona,or Ohio:Dueto the lawsof these states,the Boardis not an eligiblerecipientof QIRC’soryourCNRCwill not be issuedto you fofuploadto theBoard.PleaseobtainyourFederal

https;//www.paltpa.gov/ 10/25/2019 ____

Page 2 of 2

InSIFIJCtjDnS CheckList Name I! ]imeau of Investigation(EBI)IdentityHistorySnmmnvyCheck available at jtheliuiknotedabove. A selfquezydisclosurereportfrom theNatiOns)PractitionerData Bank 1a Repa b1k ‘ (NPDB)is required. Verificationof AOAApprovedInternshipForthmustbe received Graduate Training DIRECtLYfromthehospitalwhereyou have completedyourfirst year of training. r Contactthe licensingauthoritiesof the states,territoriesor countrieswheye helda certificate, I youhold or haveever license, penit registrationor other

. authorizationto practicea health-relatedprofession(whetheractive,inactive, Letter ótGood cxpfredor cbnent)andrequestlettersof goodstanding/verificationof Sanding (LOGS) ieensure in that state orjurisdictioa The lettermustincludethefollowing: licenseissueand expirationdate,licensestatus(currentor expired)and Iisciplinaiswnding. The letter(s) of good standing•mustbe sent directly totheBoard National NationalBoardscores(t BOME/CO?vLEYQmustbereceivedDIRECTLY lnminaflon fromtheNationalBoardof OsteopathicMedicalExaminers,Inc. Section9.1(a)of ABC-MAP tequhes that allprescñbersor dispensers,as definedin SectionSof ABC-MAP,applyingforlicensure/sppmvalcomplete at least4 hoursofBoard-approvededucationconisfingof 2 hoursinpain managementor theidentificationof addictionand2 hoursin thepractices of prescribingor dispensingof opiolds.ApplicantsseekinglicensurWapprovai . on or after July 1,2017,mustdocument,withinoneyearfromissuanceof the licensurefapproval,thatthey completedthis educationeitheraspan of an initialedupalionprogram,a stand-alonecoursefroma Board-approved coursdprovider, or acontinuing educationcoursefroman approved Oplaid CE continuingeducationprovider.The 4 hoursof Board-approvededucation needsto be completedonlyonce.Seethe Board’swebsitekrthe Opiold EducationFormsandadditionalhjormafion.

The AchievingBetterCare by MonftoringMlPrescdptionsProgramAct • (ABC-MAP)(Act) 91of 2014, as amended)isaiiailableon theLegislature’s

• websitéat: http//wwW.1e2isStatapa.us/cfdocs/Legis1IJiuconsCheck.cfin7 bcflvpeHTM&r20 I4&scsslndO&stnthLwlndQ&act=j91

The Baud’s Regulationsare availableon theBoard’swebiw.

OsteopathicManipulationTest (OM1) scoresmustbereceivedDIRECTLY - va a xam fromthetestingservice. Record of iVerificationof MedicalEducationmust be receivedDIRECTLYfromthe Gradu.fioi medicalschool. CurriculumVitaelistingAll periodsof employmentorunemployment(i.e., ae,e/cunietiIuin childrearing,researchetc.) from grathmtiónfrommedicalschoolto present Vitae The listmustbe in chronologicalordez,includeThemonthandyear,and indicatethe stateAethtoxyin whichtheemploymentoccurred.

httpwiiwww.pals,pn.gov/ 10/25/2019 L SHORT-TERM CAMP PHYSICIAN 1011/2019 ESra1uation.reults: Board/Commission: OsteopathicMedicinç

•LiceAseType; ShortTem3Camp Physician Obtained By: Application —ìo 0 j CheckList Name ‘ Instructions -J 431applicationsarcprocessedin.ofderof submission.ftthis applicatiobis not cornplete within six months, updatesof cdain sectionsand/orsupportingdocumentswillbe required. if he äpplicaffon hasnot beencompleted oneyear from. . witNn the Application We it was received,aj,plicañtswill be requiredto submita new

. application(another appJicaflonjrocessingf) and supporting documents,asnecessary.

‘ - 1ON REFUNDABLEFEE in the amountof$bffl , made pphcaton Fee ayabfr by c edit/debitcard.

. Mi health-relatedflcensees/cerffficatehbldersandfimeral dfrectprsareconsidered“mandatoryreporters”undersection6311 ofthe ChildProtectiveServicesLaw (23P.S. §6311).Therefore, ll personsapplyingfor issuanceof,an initiallicenseor Certificate . fromany o thehealth-relatedbdards (exceptthe StateBoardof VeterhiaiyMedicine)orfrom the Stat BoardofFuneralDirectors àe requiredto complete,as a conditionof licensure,3 hornsof approvedtrainingby the Departmentof HumanSewioes(DHS) •Child Abuse, onthe topicof childabuserecognitionandreporting.Afteryou havecompletedtherequitedcourse,the approvedproviderwill electronically submityourname,date of attendance,eic k the

. Bureau.For thit reason,it is imperntive.thatyouregjsterfor,thb

•courseusingthe-informationprovidedon yourapplicationfor ‘ licensure/cerfificafioaAlist of DHS-approvedchfldabuse educatidnpro4iderscanbe.foundon the Depathnentof State

. Wpbsjte.:

‘ 1)4 rn/arnolD CheckList Name Instructions J

. Wovidea recent CriminalHistoryRecords Check (CERC)from the flie jolice or other state agencythat is the official . repository for criminal history recérd information for every • stateinwhichyou havelived,worked;or completedprofessional training/studiesforthe paStfive(S) years.The report(s)must be

• datedwithin 90 days of the date thiapplicaffon iwsubiiiittcd.For applicantsliving, working or cqmpletingtraining/studiesin

. Pençsylvania,your CHRCrequestwill be automatically

. submittedto the Pennsylvania StatePoliceupon submissionof

. thisapplication.ThePATCHfee*ifl be includedatcheckout [YourPACIRC will be sent directlyto the Board/Commission. youwillbe notifiedif addiffoEalactionis required. For individualsliving,working,or completingtraining/studies CrIrnIR outside during Check of Pennsylvania the past five (5)years, in lieu of obtaining individuAlstate backgroundcheth, you may elect to provide : 30Th a stateCIffiC fromthe state in wbichyou cuntutly reside; 2W your FBI Identity History Sunny Check,available at

• hecks.

Pleasenote:For applicéntscurrentlyliving,working,Or

. complâing training/studies in california, Arizona, or Ohio;Due . to the Jawsof these states,the Board is not an eligible recipient of

• C1{RC’aoryour CHRCwillnot be issuedto you for upload to the . 3oàrd.Please obtain your FederalBureauof Investigation (FBi) Men* History SummaryCheàk availableat the link noted . above:

•. Provdean official notification of infoimafion(Self Query)from he NationalPractitionerDataBank Pleaserefer to the NPDB vebsitcforaddifiäal infoimatioaWhenyoureceivehe Da.tabanick Oft “Repanse to your Self Query,” yoüwffl need to upload it t&your

• onlineapplicatioa mcreportwill need to be upipaded,whOre prompted,in orderto submityour appliàätion. CompletqSection 1 of the Coflabonfing/Back-UpPhysician Letter from Backup Formandsubmitto the collaborating/back-upphysicianfor Physician completionofsecfibii 2. ThefOm willbeavailablefordownload md printingwhen the ipplicafionis submitted,

V4 1013112019 CheckList Name Jugnedons j [ . Cottact the licensing authorities of the slates,territories or ountries where you hold or haveeverheld a license, certificate,

‘ ,çrnth,ttgisfrafion or other authorizationto practice a health e1atedprofession (whether active, inactive, eiphed Lette f d or current) and requesl letters of good standing/verifióationof g licensure in .‘ that state orjurisdiction. The letter must include the following: . Licenseissue and expiration date, license status (current or • expired) and discipflnaxystanding. The letter(s) of good

. . . standlng.rnust be sent directly to the Board. - . F you will need to upload, where prompted, a letter from an . insurance company which verifies malpracticeinsurance coverage Wal ractice at the camp during the datesof practice in Pennsylvania, This lettermustinclude the policy number. If self-insured,provide a statementto this effect

. Section 9.1(a) of ABC-MAPrcpñres that all prescribers or dispensers, as defined in Secifén3 of ABC-MA1 applying for ljcensure/approvalcomplete at least 4 hours of Board-approved educationconsisting of 2 hours in pain mazagementor the ‘ identificationof addictionand 2 hours in the practices of prescribingor dispensing of opioids.Applicants seeking [icensure/appmvalon or after July 1, 2017, thirstdocument, vithin one year from issuance of the licensurWapproval, that they completed this education either as part of an initialedncatjcn program,a stand-alone course from a Board-approved course

. provider, or a continuing education coursefrom an approved Opiold CE àonflnuingeducationprovider. The 4 hours of Boardapproved education needs to be completed only once. Seethe Board’s. websitefor the Opioid Education Forms andadditional infoimafion.

• *me Achieving Better Care by MonitoringMi Prescriptions Program Mt (ABC-MAP) (Act 191of 2014,as amended) available is on the Legislature’s website atjjtp/1egissffitapa.us/efdocsfLegiWLTJuc6nsCheck,

ph 2bct1peHTM&)u2O I4&sessludO&smthLwftd=0 &act=191.The Board’s Regulationsare availableon the Board’s. wthsite.

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II 10131(2019

Evaluationreults: — Board/Cornmksion: OsteopathicMedicine License ¶pà: ShortTcrn•Cap ?hysieian Obtained By: Application \ 1Qo

CheckListName } Ths&uthons Allapplicationsareprocessedin orderof submission.J1’this

. applicationisnot completedwithin sb months, updates of . certainsec&ns and/orsupportingdocumentswillbe required. If the applicationbannot been completed*ithin oneyear fromthe Application dateit wasreceived,applicantswillbe requiredto submit a new application(another applicafion processlngjçç) and supporting documents,asnecessazy

. REFUNDABLEFEE in the amountof made ApplicationFee• 1frON Jjpayable by credit/debitcard. * ‘ (3. e:xi

. Allhealth-relatedllcensees/cerdficaWholdersandfuneral directorsre cOnsidered“mandatoiyrqorters” undersection6311 ofthe ChildProtectiveServicesLaw(23P.5;§ 6311)..Therefore, allpersonsapplyingfor issuanpeof an initiallicenseor certificate . fromanr of thehealth-related•boards(exceptthe StateBoardof

. Vètethaz5,Medicine)or fromthe StateBoardof FuneralDirectors arerequiredtooomplete,as a conditionof licensure,3 hon of approvedtrainingby the Departmentof HumanServices(DHS) Child Abuse onthe tépic ofchildabuserEcognitionandreporting.After you havecompletedthe requiredcourse,the appro’sked.pmviderwilI electronicallysubmityourname,date ofattendance,etc. to the

• Bureau,Forthatreason,it is impemfivethatyouregisterforthe courseusingthejnforrnationprovidedon yowapplicationfofr licensure/cerfificaflon.A list of 1)115-approvedchildabuse educationpro’ddeiican be foundon the Depaktmentof State Wçbsite.

114 I 1oI31I2G1e

[ CheckList Name Instructions 11 . I Proyide a recent CriminalHistoryRtcords Check (CNRC) from

• the state ollce or other statóagency that Is the official.. àpository for criminal history record information for evety stalein which you have lived, wd&ed, or completedprofessional.

. aining/studies for the paAtfive (5) years. The report(s) must be

. lated within 90 days of the date the applicaflàn issubzñitted. For xpplidantslivint working, or completing frainiug/studiâ in

. Pennsylvania,yourfllRC request will beautornaticafly

. submitted to the PennsylvaniaState Police uponsubmission of this application1The PATCHe *Wbe included at checkout.

. YourPA CHRC willie sent directlyto the BoarWCommission.

. Yoiiwifl be notified if adthUonal:actonis required. For . individualsliving, working,or completing training/studiesoutside of Pennsylvania during the past five (5) years, in lieu of Che k obtaining • individual state backgroundchecks, you may elect to provide BOTHa stAteCHRC from the state in whióhyou currently reside; ANDyour FBI Identity History Summary Cheàk,aâilable at flps :I/www,ThLgoWseivictjisIidendVy-historyjjgj,r

theôb. . -

•. pleasenote: For applicantscurrentlylivingsworking, or - compládng training/studiesin California, Arizonn,or Ohio: tue

• to the laws of these states,the Board is ndtan eligiblerecipient of . CIffiC’soryour CHRC will not be issued to you for upload to the Board.Please obtain your Federal Bureau of Investigation(FBI) [dentit’ History Summrny Cheàk, available at the link noted ... ‘xbóvI

, providean official notfficationof inibniiafion (Self Quay) from theNational Practitioner Data Bank Please ref&to the NPDB website-for additional infonnatioa When youreceivethe I)a ¶eponse to yourSelf Querc” yoüwill nôedto uploadit td your )nline application:The report will need to be uploaded, prompted, where in order to submityour appliàation. . Domp1et Secifoni of the Collaborating/Back-UpPbysh,ian Letter from Backup rm and submit to the collaborating/back-upphysicianfor Physician completionof Section 2. The férm wilLbe availablefor do&nload rndprinting when the applicationis submitted.

21 1013112019

j Checklist Namej InstructiOns Contact the licensingauthorities of the states, territoriesor bounthes where you hold or have ever held a license, certificate, permit,registration or other authorization to practice a health relatedprofession (whetheractive, inactive, eipfred or current) Letter of Good . . and request letters of good standing/verificationoflicensurem an g OGS ‘ that state or jurisdiction. The letter must include the following: license issue and expirationdate1license status (currentor expired) and disciplinarystanding. The letter(s) of good standing must be sent directly to the Board. Youwill need to upload, where prompted, a letter from an insurance companywhichverifies malpractice insurancecoverage at the camp duripgthe datesofpracfice in Pennsylvania.This rnsnrance letter must melude the policy number. If sel&msured,provide a statementto this effect

Section 91(a) of ABCMAP*. requires that all prescribersor dispensers, as definedin Section 3 of ABC-MAP,applyingfor licensire/approval completeat least 4 hours of RoaM-approved education consisting of 2 hours in pain managementor the identification of addictionand 2 hours ip the practices of *escribing or dispensingof opioids. Applicants seeking licensure/approyalon or after JuJy 1, 2017, must document, within one year from issuanceof the licensurel approval;that they completed this educationeither as pad of an initial education program,a stand-alonecourse from a Board-approved course provider; or a continuingeducation coursefrom an approved Optoid CE . continuing educationprovider.The 4 hours of Board-approved education needs to be completed only once. Seethe Bàard’s websitefor the Opicid Education Forms and additional infonnabon.

‘fle Achieving BetterCre by Mpnitoring MI Prescriptions ProgramAct (ABC-MAP)(Act 191 of 2014, aSamended)is available on the Legislature’swebsite atthnixllwtthvjegis. state.pauWcfdocs/LegisfU/uconsCbeck. cflpe=HTM&yr20 14&sesslnd=4)&smthLwlnd=O &aetl9I. The Board’sRegulations are availableon the Board’s

website. . 3M F 1Wá12O19

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II 1013112019

Evaluation results: BoardlCommission: Osteopathic Medicine License flpe: ShortTemj Camp Physician Obtained By: Application SA\ 1&oa9 CheckList Name — Insincifons All applications are processed in order of submission. if this application is not completed within six months, updates of certain sections and/or supporting documents will be required. If the application ha not been completedwithin one year from the 4pplication date it wasreceived, applicants,will be required t9 submit a new application (another apulicafion processine fee) and supporting documents, as necessary.

NON REFUNDABLE FEE in the amount of made Application Fee $$t1, payable by credit/debitcard...... QQ•00

‘ Althealth-related licensees/certificateholders and funeral

• directors are considered“mandatoryreporters” under section 6311

ofthe Child Protective Services Law (23 P.S. §6311).Therefore, 1l persons applying for issuance of an initial license or certificate from any of the health-relatedboards (exce),tthe StateBoard of VeterinaiyMedicine) or from the State Board of Funeral Directors 3re required to complete,as a ondition of licensure,3 hours of approved training by the Department of Human Child Abuse Services (DHS) on the topic of child abuserecognition and reporting. After you have completed the required course, the approvedprovider will electronicallysubmit your name, date of attendance, etc. to the Bureau, For that reason, It is imperØive that you register for the course using the informationprovided on your applicationfor liceusure/certification.A list of DNS-approvedchild abuse educationproviders can be found on the Department of State Website.

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of 214 101311201fl Checklist Name Instructions II I

: Contact the licensing authorities of the states, territories or countrieswhere you hold or have ever held a license, certificate, permit,registration or other authorizationto practice a health profession (whetheractive, inactive, eipfred or current) Letter of Good related and request letters of good standing/verification of licensure in Standin• ‘ that state orjurisdiction. The lettermust include the following: license issue and expiration date, license status (óurrent or expired) and disciplinary standing.The letter(s) of good standing must be sçnt directly to the Board. [Youwill need to upload, where prompted, a letter from an

‘ insurande company which verifies malpractice insurance coverage Mal racflce at the camp during the dates of practice in Pennsylvania. This bsurauce lettermust include the policy number, if sel&insured,provide a statementto this effect.

Section 91(a) of ABC_MAP*.requiresthat all prescribers or dispensers, as defined in Section3 of ABC-MAP, applying for ilcensure/approvalcomplete at least 4 hours of Board-approved educationconsisting of 2 hours in pain management,or the .. identiflcationofaddictioñ and 2 hours in the practices of tescn’bing or dispensing of oploids.Applicants seeking licensure/approvalon or after July 1,2017, must document, vithin one year from issuance of the licensurWapproval, that theyi . completed this education eitheras part of an initial eucafion program, a stand-alone course from a Board-approved count ‘ piovider; or a continuing educationcourse from an approved Opioid CE continuingeducation provider. The 4 hour of Boar&approved educationneeds to be completedonly once. See the Board’s

• 1ebsite for the Opioid Education Forms and additional

. information.

*TheAchieving Better Care by MonitoringAll Prescriptions

• PtogramAct (ABC-MAP) (Act 191of 2014, as amended) is availableon the Legislature’swebsite atLhflpilyM.\yjegis.state.pa.usfcfdocslLegisfLl/uconsCheck. cftn7bcfle=HTM&y1=2Ol4&seslnd=O&smthLwThd=0 &act=191.The Board’s Regulationsare available on Board’s website. the

14 1O/1/2O19

J__CheckListName Instructions Complete Section 1 of the CampVerificationFain and submit to Position Verification the camp for completion of Section 2. The form will be avaflable

• for download andprinting Whenthe application is submitted.

. Pleaseupload a CurriculumVitae/Resumelisting all periods of

. employmentor unemployment(i.e., child rearing, research, etc.) from graduation from your highest level of education to present ResumWCurflcnlnm (the education,completedwhich qualifies you for this license). Vitae The list must be in chronologicalorder; including the name, city

. . and stile of the employer, dates of employment or advanced education/training(include the month and year), ñnddescription

. of the practice actMty.

414 GRADUATE TRAINING LICENSE Regular Mailing Mdrns STATEBOARDOF OSTEOPATHICMEDICINE. Mouffer Odiwrv Address Pfl. BOX2649 . STATEBOARDOF.OSTEOPATHICMEDICINE HARRISBURG,PA1T1a-2M9 . flOt NORTHTHIRDSREET 717-783-4858 - HARRISBURG;PA 17110 Email: st.osteopátblcaa.gov

. • ..t :. •-L • —‘ -.. ‘.:J:— APPLICATIONFOR A RbUATh TRAININGLIcENSE FOR GRADUATESOF OSfEOPAIT C MEbICMrSCHbOLS • ‘ . .1.:: THISAPPLICATIONISDONOTUSETORENEWTOBE USEDFORINITIALGRADUATETRAININGLICENSE

APPLICATIONMUSTBE SUBMITTEDATLEAST 60 DAYS PRIOR TO THE START OF TRAINJNG

‘1 . - ‘ Submitthe $)6fee, check or money order, made pa)flle to the °Cornmonweafthof Pennsvania. 1. REFUNDABLE.Note: A processing fee of$20 willbe charged for anycheck or moneyorder returned unpaid byytur bank, regardless of Sie reason for non-payment. Yourcancelled checkis your receipt of payment.

2. Complete pages 1 and 3 ofthe application.

If docurnenb will be submitted to the Board under a name differentfrém your present hame, submit of legal a copy the doaiment evidencingme nane chaog (he., marriagelicense, divorca decree. nabiralimtlon, etc.>.

Attacha current Currlccilsn Vitae listingaDperiods &employmeñt or unnplo3knent (i.e.,childrearing, research, etc.) 4. from graduationfrom medical school to present. The listmut be in chron&oglcalorder, Includethe month and ysar, and indicatethe statelterntoty inwhich tha employment occurred.

Complete Section 1 of the Verificationof MedicalEducation and foiwardto your medical athool for compleliob of Section 2. The school must return the completed verIfication directly to the Board In an official school envelope. The !onn may be completed ONLYthree months prior to graduatIon. However, IFgraduation DOES NOTtake place, the school must notify the Board Immediately.

The Bureau of ProfessIonalend OcaspaflonalAffaIrs(BPOA),In conjunctIonwiththe Departmentof Human Services

SOction9.1(a) of ABC-MAP’requires that all presoibsrs or dispensers, as detlned InSectIon3 ofABC-MAP,epplyingfor Iicenstxe/apØrnvalcomprete at least 4 hburs.of Boird-approved education cdnslsvng of 2 hours In pain management or the Identificationof addiction and 2 hours In the fldices of prOscrIbing.or dispensing of oploids.Applicants seeking llcensvr&apprvai on or after July 1• 2017, must document wIthin-enDyear from Issuance of the Iicensur&apjroval, that they completed this education either as part of an friltialeducation program, a stand-alone ccne from a Board-approved .7. course provider, or a contlniing education course from en approved continuingeducationprovider.The 4 hon of Board- approved education needs to be completed only once. See the Boatfl Website ftr the OploldEducation FonnE and

additionalinformation. . -

‘The AchievingBetter Cars by MonItoringAfiPresipUons Program Act (ABC-MAP)(Act 191-f 2014, as smended) is available on the LegIslature’swetsite at httoWwwwJepls.state.pa.usMdocsflOqTsILl/uconsChecksm?bd,eHTM&yrn2O148ses lnthfl&smthLwlnd=3&act=1g1 ______-

f0812017) Applicantsmayalsouse the PCVS credenUalsverificationservice throughthe FederationofState MedicalBoards là

• verifytheir medical educaffonand exmnlnatjcn scores. The Board will iccept FCVS if primary source verification Is provided. However, you will need to meet oil Pennsylvania Ilcegaure requirements. MdfflonaI documents 8 sr required by the Board that are NOT Includedhi the FCVSreport but are Led In the applicationInstrublions.It Is the applicant’sresponsibilityto ensure that these addifionaldocuments am provided to the Board as outlined In the applicationinstructions.

PLEASE NOTE: Ifa pendingapplication Is older than one year fromthe date submItted and the applicant wishes to continue the applicationprocess, the Board shall require the applIcantto subnlt a new applicationIncludingthe required fee.

Inorder to completethe applicationprocess, many ofthe supportingdocuri,ents associated withthe applicationcannot be more than six months fromthe date of issuance.

: Lttfl.i;r -. -i ;t, .J ‘f i• 1. PLEASE ALLOW AT LEAST 30-60 DAYSFOR PROCESSING.

PLEASE FOLLOWALL DIRECTIONS. ANY DISCREPANCIESWILL CAUSE A baAy IN THE ISSUANCE OF A LICENSE. IT IS YOUR RESPONSIBILITY TO CONTACT THE HOSPITAL 2. REGARDINGThE STATUS OF YOUR APPLICATION. THE BOARD WILL St IN DIRECT CORRESPONDENCEWITHTHEHOSPITAL

IF THIS APPLICATIONIS NOT COMPLETEDWITHINSIX MONTHS, UPDATES OF CERTAIN SECTIONSANDIORSUPPORTINGDOCUMENTSWILLBE REQUIRED.

ITISYOUR RESPONSIBILITYTO MAINTAINA COPYOF THISAPPLICATIONANDALLDOCUMENTS SUBMITTEDTO ThE BOARD OR RECEIVED FROM ThE BOARD.

YOU MAY NOT PRACTICE IN THE COMMONWEALTH OF PENNSYLVANIA UNTIL THE PENNSYLVANIA STATE BOARD OF OSTEOPATHIC MEDICINE HAS ISSUED A LICENSE. THE LICENSE IS ONLY VALID FOR THE DATES, SPECIALTY. P1W LEVEL,ANDHOSPITALTHATARE LISTEDONThE LICENSE

EFFECTIVEJAN. 1, 2017, ACT 191 OF 2014 REQUIRESALL PRESCRIBERSANDDISPENSERSTO REGISTERFOR THEPENNSYLVANIAPRESCRIPTIONDRUGMONITORINGPROGRAM(PA PDMP). PRESCRIBERSAREREQUIREDTO QUERYTHE PA POMPSYSTEMFOR EACH PATIENTTHE FIRST TiMETHE PATIENTIS PRESCRIBEDA CONWOILED SUBStANCE BYTHE PRESCRIBER,WHEN 6. THERE IS CLINICALCONCERN THAT THE PATIENT MAY SE ABUSINGOR DIVERTING A CONTROLLED SUBSTANCE(S), ANWOR EACH TIME THE PATIENT IS PRESCRIBED AN 0P1010 DRUGPRODUCTOR A BENZODIAZEPINE.TO LEARN.MOREAND TO REGISTER,PLEASE VISIT WWW.DDH.PAGOVIPDMP. ‘I aaa aw2. Reader MalUngAddress STATEBOARDOF OSTEOPATHICMEDICINE Courier DellveryAddress p.o. Box 2649 STATEBOARD OF DSTEOPATHIO1MEDICINE

HARRISBURG,PA 17105-2649 . 2601 NORThTHIRDSTREET

7174834858 p HARRISBURG,PA 17110 Email; stsleontha

- - ,- .. . APPLICAtiONFOR A GRADU*’rE.TRA(NINGLICENSEFOR

. GRADUATES.OFOSTEdPAflIICMEDICALSCHOdtS

ThIS APPLICATION IS TO BE USED FO? INITIALGRADUATE TRAINING LICENSE DO NOT USE TO RENEW APPLICATION MUST BE SUSMIHED AT I.EAST 60 DAYSPRIORTb THESTART OF TRAiNING ARUCANTbMUSTCOIPA.EnI1EFOLWWJNG

Submitthe $fld’fee,check or money order, made payable to the ‘Commonwealth of Petlnss4vanIa. FEES ARENOT 1. Note: A processing fee of $20 willbe charged for any check or moneyorder returned unpaid byycur bank, regardless of the reason for non-payment. Yourcancelled chack Isyour receipt of payment.

2. Complete pages 1 end 3 of the application.

Ifdowmenis willbe submitted to the Board under a name differentfrom your present name, submit a copy of the 3 legal documenl evIdencingthe name change (I.e.;marriage license, divorce decree, naturalization, etc.).

Attach a currant CurIcuIumVtae listingall periods ofemployment or unemployment(La.,childrearing, research, etc.) 4. from graduationfrom medical school to present. The lIstmust be InctonoIoglcat order, Includethe month and year, and IndIcatethe state/territory InwhIchthe employmentoccurred.

Complete Section 1 of the Verificationof Medical Education and forward to your medIcalschool for completion of Section 2. The school must return the.complçted verification diractly to the Board In an official school envelope. The form may be completed ONLYthree months prior to nmdustipn. However, H graduation DOES•NOTtake place, the school must notify the Board Immediately.

The Bureu of Professional and Occupational Affairs(BPOA),in conjunctionwiththe Department of Human’Servlces (DHS),Is providingnoticeto all health-related lIcensees and funeral directors that are considered ‘mandabry mpodem’ under sectIon6311 ofthe ChildProtectiveServices Law(CPSL)(23 P.S. § 6311), as amended, that EFFECTIVEJANUARY1, 2015, Allpersons applyingfor issuance of an Initial license shall be raquirad to complete 3 hours ofOHS-approved tralning Inchildabuse recognitionand repoding requfremet as a condition of ricense. Please mvlewthe Boardwebsite forfurther Informationon’app?oved CE providers. Once you have completed a coumi[lhéappmved pmvidef’wK&ec*niclIy stthmltycuPname, date &attecthoe, eec.,to the Boirt Ch[id Abuse Conthiulr EducationPrbvMersinformationcan be found hem.

Section 9.1(a) of ABC-MAP’requires that all prescriber-sor dispensers, as defined InSection 3 of ABC-MAP,applyingfor licensurWapprovalcomplete at least 4 hours of Board-approved education consisting of 2 l-mw in paki marhagementor the identificationof addiction and 2 hoirs In the practices of prescribing or dispensing of oplods. Applicens seeking llcerur&approval on or after July 1, 2017, must doarent, withinone year from Issuance of the Ilcensure! approval,that they cornØleiedthIseducation either as part of an Initialeducation program, a star*alonu coats from a Board-approved r. course provider,or a continuIngeducation course froman approved continuingeduca&ri provider.The4 1urs of Board appmved.educaiion needs to be completed only once. See the Board’s website for the Dpl&d Education Forms and

additionalinformatIon. . . .

flbe AchI&lngBetter Care by MonitoringMIPrescriptIons Program Act (ABC-MAP)(Act 191 of 2014, as amended) Is available on the Legislature’s website at 91 (08120Th

Applicantsmay also’usethe FCVScredentialsverificationservicethrough the Federation of StaleMedIcalBoards10 verily(heirmedicaleducationand examinationscores.The Boardwillaccept FCVSIfprimarysource verification Is provIded. However, you will need to meet all PepnsylvañlaIlcegeure requirements. Additionaldocuments are requiredbythe Boardthat are NOT Inchidid In the FCVSreport butare listed Inthe applicationinstructions. it Is the applicant’s resporIbIItty to ensure thatthese additionaldocumentswe providedto the Board as outlined Inthe applicationInstructions.

PLEASE NOTE: lIe pendingapplicationis older thanone year fromthe date submitted and the applicant wishes to continue the applicationprocess,theBoad shaltrequiretheapplicanttosubmita newapplicationInciudingtherequiredfee.

Inorder to complete the applicationprocess,manyof the supportingdocuments associatedwiththe applicationcannot be morn than six months fromthe date of Issuance.

A r’JL .Kif T1 ‘ZiThaTh %S-12 ..I.r.>Lt • &3t3 1. PLEASEALLOWATLEAST30-60 DAYSFORPROCESSING.

PLEASE FOLLOWALL DIRECTIONS. ANY DISCREPANCIESWILL CAUSE A DELAY IN THE ,, ISSUANCE OF A LICENSE. IT IS -YOUR RESPONSIBILITYTO CONTACT THE’ HOSPITAL REGARDINGTHE STATUS OF YOUR APPLICATION. THE BOARD WILL BE IN DIRECT CORRESPONDENCEWiTHTHEHOSPITAL.

IF THiS APPLICATIONIS NOT COMPLETEDWITHINSIX MONTHS, UPDATES OF CERTAIN 3. SECTIONSANDJORSUPPORTINGDOCUMENTSWILLBE REQUIRED.

IT ISYOURRESPONSIBILITYTO MAINTAINA COPYOF THISAPPLICATiONANDALL 4. DOCUMENTS SUBMITtEDTOTHEBOARDOR RECEIVEDPROM-THEBOARD.

YOU MAY NOT PRACTICE IN THE COMMONWEALTHOF PENNSYLVANIAUNTIL THE PENNSYLVANIASTATE BOARD OF OSTEOPATHICMEDICINEHAS ISSUEDA 5’ LICENSE. jff LICENSEIS ONLYVALIDFOR THE DATES,SPECIALTY,PGY LEVEL,ANDHOSPITALTHATARE LISTEDONTHELICENSE.

EFFECTIVEJAN. 1, 2017, ACT 191 OF 2014 REQUIRESALLPRESCRIBERSANDDISPENSERSTO REGISTERFORTHE PENNSYLVANIAPRESCRIPTIONDRUGMONITORINGPROGRAM(PA PDMP). PRESCRIBERSAREREQUIREDTO QUERYTHEPA PDMPSYSTEMFOR EACHPATIENTTHEFIRST TIMETHE PATIENTIS PRESCRIBEDA OONTROLLEDSUBSTANCEBYTHE PRESCRIBER, 6. WHEN THERE iS CUNICAL-CONCERN THAT THE PATIENT MAY BE ABUSING OR DIVERTINGA CONThOLLEWSUBSTANCE(S),ANDIOREACHTIMETHEPATIENT IS PRESCRIBEDAN OPIOID DRUG PRODUCTOR A BENZODIAZEPINE.TO LEARNMORE ANDTO REGISTER,PLEASE VISIT WWW.DDH.PA.GOVIPDMP. I

Dt\v 1 oa4 (0512017) RequbrMalllnnAddress STATEBOARDOFOSTEOPAThICMEDICINE . CourierDellVervAddress PD. 5dk2649 STATESOARDorOflOPAThICMEDICINE HARRISBURG,PAIn 05-2M9 . 2501 NORTHTHIRDSTREET 717-1834555 . HARRISBUR.PA 17110 Email: st-osteoogtblooa.gcv

-: ...,,. %u;.. ‘4-•.. - “ ;-... APPLIATION FOk A GRADUATEWAININGLICENSEFOR GRADUATES OF àstEopAffi1ci1OICALScHôOLs.

• . t. ‘ —. — . . — THISAPPLICATIONIS to SE USEDFOR INflAL GRADUATEWAININGLICENSE DONOT USE TO RENEW APPLICATIONMUSTBE SUBMITTEDATLEAST 60 DAYSPRIORTOTHESTARTOF TRAINING C AnucANts MustcoMpLEWtIEpoaowigG 4 ...... —:tt.: • :‘. ‘cicc’. ..L__r!? ‘ISubmitthe6tee, checkor mcneyuder, madepayableJothe ‘CommonwealthofPannsytvanla.”FBES ARENOT REFUNDABLE.Notet A processing lee of $20 wlUbe charged for any check or money order returned unpaid byyour bank, regardless ofthe reason far non-payment Vourcancelied check Isyour recelpUofpayment.

2. Complete pages 1 and aol the appilcatlon,

if documents wfltbe submitted to the Board under a name differentfrom your present name, áubmlt a copy of the 3 legal document e’idenclngthe name change (i.e. marriage license, dI’orce decree, naturalization,etc.).

Attacha current CuiriculumVitae listingallperiods of employmentor unemployment(I.e.,childrearing, research, etc.) 4. from graduationfrom medical school to present. The list must be Inchronologicalorder, Includeth month and year, and Indicatethe staieltenitoiyInwhichthe employmentoccuned.

Complete Section 1 of the Verificationof Medical Education and Miward to your medical school for comlellon of Section 2, The school must return the completed verification directly to tile Board In an officIalaqiooi envelope. The form may be completed ONLYthree months prior to graduation. However, if graduation DOESNOTtake place, the school must notify the Board ImmedIately.

The Bureau ofProfessionaland OcwpallonaiAffairs(BPOA),Incorunction withthe Department of.Human Services (OHS),Is providingnoticeto all health-relatedlicensees and funeral dIrectorsthatare considered ‘mandatory ieportsrC under section 6311ofthe ChildProtective8cr ices law (CPSL)(23 P.S. § 8311),as amended, 11* EFFECTIVEJANUARY1, 2015,’alIpersons applyingfor Issuance of an Initiallicenseshall be required to complete3 hours ofOils-approved trainingInchildabuse recognitionand reporting requlrthnentsas a conditionof Ilcensum. Please revlewthe Boardwebshe forfuflher Infonnatlonon approved CE providers; Once,youhavecompleteda cbüió theapprovedpro1deTtlIe!attEonIcaiIysubmit9ourname,date crattn6anoe, etc., to theBOa d:cnflcI Abuse ContinuingEducationProviders Informatlapcan be fgund here.

Section 9.1(a) of ABC-MAP’requires that allprescr[bers or dispensers, as deflnud in Section 3 ofABC-MAP,appi,4ñg.for ilcensurelappmval xmpielç at least 4 hours of Board-approved education corIsfing of 2 hours In pain management or the Identificationof addiction and 2 hours In the practicesof presibIng or dlsperlng of oplolds. Applicantsseeking Ucensumlapprovalonor afler July 1,2D17.must documentwithinone year fromIssuance of the Ilcensum! approval,that theycompleted this education eitheras pariof an Initialeducation program, a stand-alone course from a Board-approved 7. courseprovider,or a continuingeducationcourse froman appr&vad ccntinul% education provider. The 4 hoursofBoard- approved educatiOn needs to be completed only on. See the Board’s website for the Oplold Education Forms and addNon!lInformation. .

The Mhielng Belier Care by Monltodrigil Prescriptions Program Mt (ABC-MAP)(Mt 191 of 2014, as anlended) Is available on theLegl&abre’swebslts at (O12D17) Applicantsrfiayalo use the FCVS credentials verificationseMca ththugh the Federaflowcf StaleMedicalBoards to verI’ their medical education and examinationscores. The Board will accept FCVSIf primery source verification •Is prâtdad. However, you will need to meet all Pennsylvania Ilcensure requIrements. AddltlOnaldocurnsnts 8. are requiredby the Boardthat am NOT includedInthe FCVSreport but are listed in the applicationinstructions.‘IIIs the applicant’sresponsibflhtyto ensure that these additionaldocuments are providedto the Board as outlined in the applicationInstructions.

PLEASENOTE: Ifa pending applicationIs older than one year from the date submitted and the applicant wishes to continue the applicationprocess, the Board shall require the applicantto submit a new applicationincludingthe required fee.

Inorder Laccmpletethe applicationprocess, manyof the supportingdocuthents agsociated,withthe applicationcannot be more thansix monthsfromthe date of lssuan.

1. PLEASEALLOWATLEAST3O-6ODAYSFORPROCESSING.

PLEASE FOLLOWALL DIRECTIONS. ANY bISCREPANCIES WILL CAUSE A DELAY IN THE ISSUANCE OF A LICENSE. IT IS YOUR RESPONSIBIUV( TO CONTACT ThE HOSPITAL 2. REGARDINGTHE STATUS OF YOUR APPLICATION. ThE BOARD WILL BE IN DIRECT CORRESPONDENCEWITHTHEHOSPITAL

IF THIS APPLICATIONIS NOT COMPLETEDWITHIN SIX. MONTHS, UPDATES OF CERTAIN 3. SECTIONSANDIORSUPPORTINGDOCUMENTSWILLBE REQUIRED.

ITIS YOURRESPONSIB!LIlY TO MAINTAINA COPYOF THISAPPLICATIONANDALLDOCUMENTS 4. SUBMITra TOTHEBOARDORRECEWEDFROMTHEBOARD.

YOU MAY NOT PRACTICE IN THE COMMONWEALTHOF PENNSYLVANIAUNTIL THE PENNSYLVANIASTATE BOARD OF OSTEOPATHICMEDICINEHAS ISSUEDA LICENSE. 5. ThE LICENSEIS ONLYVALIDFOR ThE DATES,SPECIALTY,P1W LEVEL,ANDHOSPITALThAT ARE LISTEDON7HE LICENSE

EFFECTIVE JAN. 1, 2017, ACT 191 OF 2014 REQUIRESALLPRESCRIBERSANDDISPENSERSit REGISTERFOR ThE PENNSYLVANIAPRESCRIPTIONDRUGMONITORINGPROGRAM(PA PDMP). PRESCRIBERSARE REQUIREDTOQUERYTHEPA PDMPSYSTEMFOREACHPATIENTThE FIRST TIMEThE.PATIENTIS PRESCRIBEDA CONTROLLEDSUBSTANCEBYTHE PRESCRIBER,WHEN 8. THERE IS CLINICALCONCERN THAT ThE PATINT MAY BE ABUSING OR DIVERTING A CdNTROLLEDSUBSTANCECSLAND/OREACHTIME THE PATiENTis PRESCRiBEDAN OPIOID DRUGPRODUCTOR A BENZODIAZEPINE.TO LEARNMOREANDTO REGISTER,PLEASE VISIT WWW.DOH.PA.GOVIPDMP,. PHYSICIAN ASSISTANT wr3112019 Evaluationresults: BoardlCommisiion: OsteopathièMedicine Licebse Type: OsteopathicPhysician Assistant

Obtained By: Application .

- j_CheckList Name.._jj Thstñictlons__L 4.11applications are procesSed•In order ofaubmission. Ifthis application Is not à6mpleted within six months, updates of certain sedilons and/or support!ngdocuments willbe 4ppJicaffon reqUlrei ifthe application has not been completedwithln one year fromthe date Itwas •reàeived,applicants willbe required to stibmita new application(änothei application processing fee)and supporting documents, as. necessary.

. NONREFUNDABLEFEE inthe amount of $941L made. payable by credit/debit card. ifthe applicationhas not been completed withinone year fromthe date ltwas received, 4 II if Fee applicants wjlIbe required to submit a flewapplication : (anotherapUcatIon DmcessIngJ) and supporting documents, asnecessary. . $115.00 AM • health-relatedlicensees/cefificateholdersandftnl ofdirectorsareconsideied“mandatoryreporters”un er section6311 the ChildProtectiveServicesLaw(23 P.S.§6311). Therefore,

. afipersonsappl4ng for issuance of an initial licenseor certifióate

. fromany ofthe health-relatedboards(exceptthe StateBoardof . .. VetednazyMedicine)or fromthe StateBoard of Funeral Dfrectots are required to complete, as a condition of licensure;3 hoiñs of bythe Departmentof Child Abuse CE PW° trnng Ijuma Sernces (DHS) onthe topicofchild abuserecognitionandreporting.Afteryou .

. iave completedthe required couxe; the approvedprovider will electronicallysubmit your name,date of attendance,etc.to the Bureau.Forthat reason,it is imperativethatyou registerfor the courseusingth infoimationprovide on your applicationThr . ilcensure/cetifficaifon.A list of DHS-approvedchild abuse. eduèaUonproviderscan e foundon the Peparthientof State Website. Databank

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of 214 - 10/3112019 CheckList Name j bstrñctions Contact the National Commissionoh Certification dfPhysiciat Exam Results kssistants,kp. (NCCPA)and arrange lb your exam scoresto be sent directly to the Board. Contact the licensing authoritiesof the states, territories or countrieswhere you hold or have ever held a license, certificate, pennit,registation or oth* authorizationto pracdcea health- rolatedprofession (whether active, inactive, expired or current) Letter of Good and request letters of good standing/verificationof licensure in • g aI ‘ that state orjuristhction. The letter must include the Thllowing! license issue and expiration date, license status (current or expired) and disciplinary standing. The letter(s) of good standing must be sent directly to the Boar4. Section 9.1(a) of BCMAP.t requires that all prescribers or dispensers, as defined in Section3 of ABC-MAP,applying Thr Jicensurelapprovalcàmplete at least 4 hours of Board-approved educationconsisting of 2 hours ih ain management or the identification of addiction and 2 hours in the practices of prescribingdr dispensing of opioids. Applicants seeking licensure/approvalon or afterJuly 1, 20.17,must document, within one year from issuanpeof the Iicensurp/approval, that they completedthis edUcationeitheras part of an initial educatIon program, a stand-alone coursefrom a Board-approved - course ,rovidèr, or a continuing education coursefrom an approved Opiold CE educationconfining bducaffonpwviden The 4 hoursof Board-approved needs to be completedonly once. See the Board’s websitefor the Oploid EducationForms and additional

inThrmation. -

*The Achieving Better Cs by MonitoringAll hescriptiohs Program Act (ABC-MAP) (Act 191 of 2014, as mended) is available on the Legislature’swebsite • at httfJywwjcgis.state.pa.usIcfdocS/Legis/LVuconsCheck.

dfinThLflmjThyr=20 I4&sesslnd=O&srnthLwlnd=0 . a&19l. The Board’s Regulationsare availableon the Bond’s

* wébsite.

3,4

‘ I 1w1ao19

• CheckList Name Instructions Youwill need to upload,whereprompted,a current Curriculum VitaelistingaJ!periodsof employmentor unemployment(i.e.,

. childrearing,research, etc.) fromgraduation fromthe physician assistnt programto presônt Thelistmust be in chronological order,includethe monthandyear, andindicate the state/temtory vitae • inwhichthe employmentoccurred.If you are a new graduate withno employmentyou willneed toprovide a statementto this . effect The resume/curriculumvitae will needto be uploaded,in orderto submit your application.

414 - 1013112019 Evaluation results: Board/Commission: OsteopathicMedicine License lype: OsteopathicPhysicianAssistant Obtained By: Application a Q2a CheckList Name Instructions It appJicaflos ate processed•In order otsubmission. Ifthis• applibation Is not completed within six months, updates of certain sections andIor supportingdocuments willbe àpplication reqWred1Ifthe applicationhas not been completed within one yer from the date itwas received, applicants Willbe required to submit a new applibatlon (another application • processjngjQfi) and supportingdocuments, as necessary. NONREFUNDABLEFEE inthe amount of $3&tOflnade payable by credit/debit carct.Ifthe application has not been completed withinonà year from the AppiicauonF date itwas received, applicants willbe required to submit a hew application . documents,(another application frocessinój.cg) and supporting asnecessaty. - $25. 00 411health-relatedlicense&cerffficateholderjand funeral

. dfrectorEare considered“rnandatoiyreporters”underseàdon6311 of the ChildProtective ServicesLaw(23 P.S. 6311). Therefore, all persons applying for issuanceof an initial license,or certilióate

• om any of the health-relatedboards (except the State Boardof Veteiinar, Medicine) or frQMthe State Board of FuneralDirectors are required to complete, as a conditionOfliceusure,3 hoursof approvedtrainingby the Departmentof Jjiimsn Setvices Child Abuse WHS) opth topic of.childabuserecognitionandreporting.Afle,?you havecompletedthe requiredcourse, th,eapprovedproviderwill electronicallysubmit your name,date of attendance,etc. to the Bureau.For that reason, it is imperativethat you registerfor the courseusing the mformabcmprovidedon your applicationfor licensure/cerfifioatioa A listof DHS-ap*oved child abuse educationproviders can be Ibundon the Deparffiientof State Website.

114 Name Instructions Lchedt 11 Provide a recnt CriminalHistory RecordsCheck (CIIRC) from

• the.stite police or other state agencythat lathe official

. repositoryfor criminal history record information for ever)’ . stMeinwhichyoUhave jived,,worked,or oornpletedprofessionEL . - ainingfstudies for the çst ten (10)yeaa The i’eport(s)mustbe dated within9O days of the date the applicationis submitted. For applicèntsliving, working, or completingtraining/studies in

. Pennsylvania,your CHRC request will be automatically submitted to the PennsylvaniaState Police upon submission of thisapplication.The PATCHfee will be includedat checkout YourPA CHRC will b sent directly to the Boar4/Commision.

• Youwill be notified if additional action iErequired. For. criminal aistory thdMduals living, working, or compiethg ftaininWstudid outside of Pennsylvaniaduring the past tea (10) years, in lieu of obtaining Check . individualstate background checks, you may elect to provide BOTH a state CHRC fitm the state in whichyçu currently reside, AND y&irFBI Identity History Summary Check a’’ailableat nps://’Anww.fbi.gov/sezvices/cjisIideuthyAistory-surmnaiy bliecjcs,

. ?leasenote: For applicants.cprrêntlyliving,working, or conipJetingtraining/studies in California,Arizona, or Ohio: Due to the laws Ofthese states, thefloard is not an eligible recipientof - CHRCs or yrnir QIRC will not be-issuedto you for upload to the . Board.Please obtain-yourFederal Bureauof Investigation (FBI) identity History Summary Check, availableat the link-noted above; PIDvidean official notification of information(Self Quezy)from

. . the National Practidonef Data ank Please refer to the NPDB webite for additionél when you receive the Databank Ds.nOft ormton. awL. “Res,ónse to ydw Self Quezy, yàu will needto uploaditto your Dulineapplication. Thereportwillneed tobe uploaded, where rompted, Jh drder to sØmit your application. .. Completi Section 1 of the \Fedficatioh•áf EducaflOnand - rorwardto.your physician assistant programfor completion Education of Section 2. The school must return the completed

Verification . verification directly, to the Board. The form will be avéliable for dowfljbad and printing when the .. application Is submitted.

214

I 10/3112019 _CheckLiát Name Insfrudllons

. Contact the National Commission ob Cer ificationdf Physician Exam Results Assistants,Inc. (NCCPA)and arrange for your exam scores to be

• sent dfrectl to the Board. Contact the licensing uthorides of the §tates,territories or counthes where you hold or have ever held a liqense, certificate, ,ermit,registration or other authorizationto practi c a health- relatedprofession (whether active, inactive,expired or current) Letter of Good .. and requestletters of good standibg/vedfcation’oflicenswein’ stana;nn a oas’ ‘ that state orjuñsdictiou. The letter must include the following: license issue and expiration date, license staW (current or • ‘ expired) and disciplinary standing. The letter(s) of good standing must be sent directly,to the Board .. Section 9.1(a) of ABCEMAP requires that all prescribers or

. ‘ dispensers,’asdefined in Seclion of ABC-MAP,applying for licenAure/approvalcomplete at least’4hours of Board-approved . education cànsisting of 2 hours in pain nianagethentor the . . identificationof addiction and 2 hours in tjiepractices of prescribingor dispensing of opioids.Applicants seIdng

. . [icensure/ápprovalon or after July 1, 2017, must document . withinoneyear from issuance of the.licensurç/approval, that they . co3npleed this education either as part of an initial education program, a stand-alone course from.a Board-approved course ,. . prOvidw or a continuing education cohrsefrom an approved Odioid CE continuing education provider. The 4 hours of Board-approved r education needs to be completedonly’onc&See the Board’s . wthsite for the Opioid Education Fozmsandadditional hiférmation. . . . *TheAchievingBetter P b MonitoringAll Prescriptions. . Program Aát (ABC-MAP) (Act 191 of 2014,as wptniled) is available on the Legislature’swobsite state.pa.us/cfdocslLegislLJlüconsCheck.

cft&WTypeBTM&y=2Oi4&sessInd=a&smthLwJnd=O . &act=191 The Board’s Regulations,are availableon the Board’s webaite.

3/4 1Ol31I2OlD CheckListName j Insfrucions

. Youwillneedtoupload,whereprompted,a currentCunioulum Vitaelisting211periodsof employmentorunemploymdñt(i.e.,

. childrearing,research,etc.) fromgraduationfromthe physician assistantprogtamto present.Thelist must be inchronological order,mcludethemonthapdyear,and indicatethestate/territory flacI in whichthe employmentoccurred.if you area newgraduate withno employmentyou willneed to providea statementto this effect Theresume/curriculumvitae willneedtobe uploaded,in

, order,to submityourapplication..

4,4 10/31120W Evaluation results: Board/Commission: OsteopathicMedicine License Type: OsteopathicPhysicianAssistant Obtained fly: Application 3uki ii oaU Name__II Instructions J_CheckList All appflcations are processedin order of subrnis&on. Ifthis application is not completed within six months, updates of

- certain sections and/or supporting documents will be• Application., required: Ifthe application has not been completed within . one year from the date it was received, applicants willbe required to sUbmita new applibation (another apiIcatlon processing jçg) and supporting documents, as necessary. NON REFUNDABLEFEE in the amount of O4t . ., madè ‘ payable by credit/debit card; ifthe application has not been withinone year from it-was Application Fee completed the date received, applicants willbe required to submit a new application (another application processingjgg) and supporting documents, as necessary. Si go.:g All health-relatedlioensees/cerffficateholdersand Ilmeral

. directors are considered “mandatory reporters”under sectiort 6311 of the ChildProtective Services Law (23P1S.§6311). Therefore, all persons applyingfor issuance of an initiallicense or cerfifiãate from any of the health-related boards (exceptthe State Board of VeterinaryMedicine) or frQmthe State Boardof Funeral Directors ‘ are required’tocomplete, as a conditionof licensure, 3 hours of approvedtraining by the Department of Services Child Abuse CE Human (DHS) on the topic of child abuse recognition and reporting. After you nave completcdthe required course, the approvedprovider will electronicallysubmit your name, date of attendance,etc. to.the

. Bureau. For that reason, it is imperative thatyou register fbr the coursà using thi information provided onyour application :for. licensurclcettiflcafion.A list of DHS-approvedchild abqse. educationproviders can be found on the Departñientof State . Website. ..

.114 10131120IS _ChedkList Nabw_[ Instructions Provide a recent Criminal History Records Che&(CNRC) from the state police or other state agency that is the official repository for criminal history record Information for every

• you have Uved,.worked,or completedprofessional training/studiesstate in which for the past ten (10) years. The report(s) must be dated within 90 days of the date the applicationis submitted, For applicants living,working, oxcompletingtraining/studies in

‘ Pennsylvania,youi CBR.Crequest will be automatically submittedto thePennsylvania State Police upon submission of this application.The PATCHfee will be includedatcheckout YourPA CNRCwill be sent directly to the Board/Commission.

• Youwill be notifiedif additional action istequket For living,working, or completing training/studies outidc Criminal Wsto y individuals of Pennsylvania the past ten([0) years,Lulieu dfcbta4ning Check• ding individualstate background checks, you may elect to provide BOTH a.sbte.CIWC from the statejn whichyou currently rçside, AND your FBI Identity History SumtharyCheck,available at ps ://www.thi.gov/aèrvices/cjisñdèntityhistoxy-summary checks.

Pleasenote: For appliäants currently living,working, or cothpletingtraining/studiesin California, Arizona,or Ohio: Due to the laws of thesestates, the Board is not aneligible recipient of ames or your CHRC will not be issued to you for upload to the Board. Please obtain your Federal Bureau.ofInvestigation (FBI) Identity History Summary Check, availableat the link noted above. Provide an officialnotification of information(Self Query) from the National Pracddonet Data Bank. Pleaserefer to the NPDB website for additionAlinformation. When youreceive the Databank Rej) “Responseto your Self Query,” you will needto upload it to your online appication The report will need to be uploaded, where

• prompt&1,in order to submit your application..

Complqte Section 1 of the Verificationof Educatiod and f&ward to your physician assistant program for completion &dncalion of Sectlon2. The school must return the completed Vedlicafion weriflcation directly to the Board. The form will be available for download and printing when the

. application Is submitted.

214 1013112019

CheckList Name ff Tnsfrucio4s Contactthe National Commissjon oh CertificationdfPhysioian Exam Results %ssistants,ho. (NCCPA)and arrange for your exam scores to be eut dfrectly.tothe Board. Dontactthe licensing authorities of the states,territories or • coimthes whew you bold or have evei hel4 a license, certificate, permit registration or other authorizationto wactce a health relatedprofession (whether active, inactive,expired or cuffent) • and request letters of good stanthng/venflcaUonof licensure in that state orjunsdicton. The letter must includethe following:

• license issue and expirationdate, license status (current or expired) and disciplinary standing. The letter(s) of good sanding must be sent directly tothe BoarL Section 9.1(a) ofABC44AP* requlits that all prescribers or dispensers,as defined in Section 3 of ABC-MAP,applying for licensure/approvalcomplete at léast4 hours of Board-approved educationconsisting of 2 hours in pain managementor the identificationof addiction and 2 hours in thepractices of

. ,rescribing or dis5ensing of opiolds.Applicantsseeking licensurWapprova]on or afterJuly 1,2017, must document, within one year from issuance of the licensure/approval, that they completedthis education either as part of an initial education program,a stand-alone course from a Board-approved course provider, or a continuing education.coursefrom an appthved Opidd . continuingeducationprovider. The 4 hours of Board-approved . ducaflon needs to’be completed only once.See the BoaM’s websiteforthe Opioid Education Forms andadditional .

‘ Information. .

‘The AchievingBetter Careby MonitoringAMPrescriptions • ProgramAct (ABC-MAP) (Act 191 of 2014,as amended) is available on the Legislature’swebsite atj hftp//wwwlegis.state.pa.us/cfdocsfLesILVuconsCheck.

thn?bctTypeHTjvl&yr=20 14&sessTnd=O&nthLwI.nd=O

‘ act=l9l. The Board’s Regulations are availableon the Board’s ‘ website.

3,4 101311201D CheckList Name Icions

. Youwill need,to upload;whereprompted,a currentCurdeuhim . Vitaelistingfl.perioth of employmentor unemployment(i.e., . childrcañng,research,etc.)fromgraduationfromthephysician assistantprogramto presett. ThelistmuAtbe in chronological Resumelcu culum at )rder,includethe monthandyeaz andindicatethe state/teffitoty

. hiwhichthe employmentocciüred.if you are a new graduate withno employmentyou willneedto providea statementto this effect The resume/curriculumvitaewillneed tohe uploaded,’in

• order,to submityour application.

4,4 SUPERVISING PHYSICIAN SUBSTTIUTE LICENSE PRACTICE piiysicini PHYSiCIAN SUBSTITUTE . PNARY PHYSiCIAN LICENSE PRIMARY pitvldsd policy p,ciiasad This •appllcsifon Pld&Pitof REFuNpMC.E. ofpayirrnt date the FEL each approval. The temøomWconrnence check and PLEASE PLEASE PLEASE application cENSE PIA ,. appltcs&n the • . temporary of prost physIcian

STATE ormorwy . whIle Submit Issuance. apption answers 4(Jta Proof NUMBER NUMBER Complebai CountIes, SUPERVISING In SUPERVISING PRINT NOTE: NOTE: ADDRESS: lnwzrunce ASSISTANT afjnsurance/cadwscata ASSISTAW includes prncess,’the NL:-

APPLICATION arder ALLOW SUPERVISOR SUPERVISOR’S perftnlnq of theSJSO BOARD process, ss&stant euthoriatlori Email: of order ORPPEAI.L cunsnt to Thö UCENS for.the

W RcisIrMaflIna THIS will Upon Drofnisbrtal the all n of or AT returned PRIOR tie portdthg require questions insute a below maiy Bawd ststeopMhldtya.th. practice NAME: liaNUty OF APPLICATION 717.Th3-4555. PHYSICIAN arént Baardto Attach LEAT receipt physician’ ‘ cannot fee. NAME: OSTEOPATHIC to PI.EASE Items. additional of shaD TO unpalØ appkaflon BY prectice insurance PJFORMA1TON. the and . Make with the in provided ala HibIfltr be 120 THEBOARb THE lieu. require mull FOR acco,dnce fee supporting Failure a6stsañt rect Address flMtonsd suppatlng by comMeta checik DAYS and NOTE Is processing PENNSYLVANIA Lest ‘: your temñamrv co%er%O Include IS by valid Is Insurance the to

REGISTRATION Iwiffen eppibationfoon t oidw . FOR the or bank, provide . FOR

appflnt MLCWE services documents for doarmenlatlon. with money thnptoyn . A ‘ tn If epp!lffon. ISSUING ‘ the than USE agreement. ftrthe lime. 120 Via PHYSICIAN another PROCESSINQ regardless’ authorization the physician one coverage one days . oftier . ONLY 10 ridan In pending physician - . . for or associated submIt ______the year ATEMPORMY $TATE With application. - morn ONLY Vii the agreement payable . . — of BY Commonwealth assistant’s for all w.WAiwn fmrn ASSISTANT the a Board nitten of ______to &sistant A requested new while BOARD

bF the the miscn 3,ndlca. . with PRIMARY

AS the to applltevon followIng THE Is will phvslclen the

the 4p,: date agreement the amount STATE idenuca! .

A name for Issue tommoywaalth written inhnnallon appUcaUm OF WRfl7EN AUTHORfl’Y submitted

SUPERVI CANNOT nbn-peymont . NUMSEt PRACTICE Fkit First of A SUPERVISING HOrns OSTEOPATHIC of and pmcvsslag BOARD

Inzfln a for Pennsylvania. 51.000.000.00 ásbtani agreement sakmftted letter HARRISBURG, sU Indicate will carindt including end supervisors, . AGREEMENT •—oer PRAC11CE result TELEPHONE iUHiOH2rIg OF

the to the foe ______Your of throu9h that with

INC -. be is required

OSTEOPATHIC In Pi(4pcE Perwls)qvar& applicant of signatures, bplng PHYSICIAN per a morn cancelled Proctor MEDICINE. $20.00 they denial this submit ccJrrence

PHYSICIAN the PA s&f4nsumnce.pencnsy evaluated fee. than an . FIrâL application. wishes of WI physlpian 17110 one - Insurapce covered theok dales,

temporary six In be cider FEES application APP months or cflarged to MEDICINE for is and clakus tjddie ______conbnuè assistant A. your to undeithls final ARE

approval, must complete complete complete from ror made. receipt Board . for - NOT any The the be (a (0112017)

PENNSYLVANIASTATEBOARDOF OSThOPATHICMEDICINE i_C -It .‘xi A PR RY cp 4I(

. USTYOURSPEC1ALTIES: — y. No r; iy1j tfl DO YOUHOLDHOSPITALSTAFFPRIVILEGES? ) I i::t4 iFYES LISTHOSPITAL(S):

In • I Willdirect and exertise supervision over the named physician assistant accordance wth the miss and regulations of the Stale Board of Osteopathic Medicine.

• I verifythat I have reviewed the Osteopathic Medical PractIce Act and Regulations of the Slate Board of Osteopathic Medicine. -

• I renIze that I am obIIated to comply wIUiall provisions of the Act and Regulallons Intluding those provisions that require me to notify TheBoard &the tennlraUon of my agreement to supervise the physIcan assistant. and • I recognIze that Iretain fullomfessi& and least msoaislblIftv (or the Derfotmanceofthe ôhnldan asaTstnt the care and Lrpanent of the pyician essiskats patients. • I verifythat the statements in this application and written agreement am tue and coimct to the best of my Imowlédge, informationand ballet.

• I undartand that false statements are nude subject to the penalties of 15 Pa. 0.5. §4904 relating to unsworn fabIflUon to ai4hodVn and may result Inthe suspension or revocation of ny registration. • Iwillpmvfde all substitute .upaMslnii physicians with a copy of the anDroved supeMsinp written agreement • The phyiclan assistant identified in this application will only work with the primary supervising physfclan and hlsTher substitute physician assistant supervisor(s). • The physician assistant will only pmlde medical seivicçs to the pallet under the cam of the primary and subsUMe supervisor(s) and WILL NOT Dractice if the supervising -physician or an authorized substitute supervisor is flat available.

PRIMARYSUPERVISINGPHYSICIAN (Printed Name): L

PRIMARYSUPERVISINGPHYSICIANSiGNATURE:

PHYSICIANASSISTANT(Printed Name):

pjjfltCiAN ASSISTANTSIGNAWRE:

PLEASE NOTE:. The primary supervisor’s responsibilities include:

e Providing a copy of the final Board appro1eed wriften agreement to all substitute WpervisorS. • Maintaining a current list of all locations where the physician assistant will perform duties. • Maintaining a current list of all substitute supervisors under which the physician assistant will work. • Notifying the Board of changes to the primary practice location utIlizing a written

• agreement change form. . Ensuring that the physician assistant wili not practice without supervision by either the primary supervisor or an authorized substitute supervisor.

2 (0112017) PENNSYLVANIASTATEBOARDOP OSTEOPATHICMEDICINE

. WRITTENAGREEMENT

Last - First - IbdIe NAME- PRIMARY SUPERVISINGPHYSICIAN:

•Lust Fast IlIdde NAME—SUBSTITUTE SUPERVISINGPHYSICIAN:

- Last Fist MCdle NAME— PHYSICIAN ASSISTANT:

INSTRUCTIONS: Please provide the followIng information (typed) for uesUon I on 8.5’ x Ii’ sheets of paper and attach to this form,The Ibtormatlon on this agreement mustbe agreed to by eli supervisors (primary and substitute).

1. Describe the Funclensltasith to be d&egatsd to Thephysicianassistant

2. Providethe details describingthe time,place aria manner ofsupeMsion end directionyou willprovide the physician assIstant, lnckidin the frequencyofpersonal contactwiththe physIcianassistant.

2. If the physicIanassistant will practice In a hospItal andlor a surgical center, provide the name and address of each hospHal!surglcslcenter-below. if more than three hospItaIs/sulcal centers, please providethis informationon a separate

• sheet ofpaper. N.meofHosptftwsurglciiCenter

NameorHoiiiiUSiijraiEtaiiiii .

Nameat Hespihv5urgiealCanter Mdress

No 4. WIllthe physicianassistant prescribeand dispense drugWtherapeutlcdevices?

IIyes. pleaseldenti&whichcategories ofconbtlled substances may be presqibed and.dispansed?

ci None LI Schedule II LI.Schedule III Ci Scheduie.IV Ci Schedule V

Listbelawsny specificdrugs that the physicianassistant WILLNOTbe penniftedto prescribWdlspensa.

Proof of professional liabilityInsurance coverage for the physician assistant named above Yes No 5. ($1,000,000per occurrence or claims made) is Inciudcd with this Writtenagreement applicatlen.

3 ______—

- (0V2017)

PENNSYLVANIASTATEBOARDOF OSThOPAtHIGMEDICINE - .kfl..nrs t - r

‘ • ‘trn.’ -.;._:•- — - 7.2%’R’,_ -: •. — V-a-- - ..., t-—” ‘&‘— - ‘. — - - —- — — . ‘ —‘r--’ nt’— [Sit flit r.tddla NAME—PRIMARY SUPERVISINGPHYSICIAN:

• • -- last flat M. NAME— PHYSICIAN ASSISTANT:

The supoMshg physIcian,whether primaryor secondary, must countarslgn 100% of the patient records completed by the physician assistant withina reasonabletime,whIchshallj3,cxceed n days duringeach of thofotowtngcases.

• . The fIrst12 monthsof the physicianasslsffinrs practice post graduationand afterobtaining (censure. • The fIrst12 monthsof the physicianassIstant’spracticeInanew specially. - • The firstS monthsof the physicianassistants practice Inthe earns epeclty undera new primarysupervisor (unless, the new prImaryaupewlsorwps registered as a substitutesupervisor forat least sixmonths underanother writtenagreement).

if esiswerYesInSacties Ayoudonotnoad Ia complete Seclion LI? you answer Nob SaollonAtlisn you must campin Section5. INSTRUCTIONS:you — -i NO I v,IHcountersIgn100% chart review of the physicianassistant’s patient rpcordcwithln[ho requIred10 day period.

‘° No 05515t0njs In I have been registered as a cttsUhjto supervisorforthe above identifiedphysicIan prnctico the same specially for at least clx months and I Intendto deviate 1mmthe 100%chart reviewof the physician asslstanrs patient records withinthe requIted10 day period?

if you Intend to deviate from the 100%chart review, providespecific details belowregardinghow you willselect patiehl records formV*wand withwhatfrequencyyou wilt reviewpatientrecords. Ths infonnatlonshould Includespeci such as the percentage of patientcharts, specifictypes or categorIesofpatientceses, etc. Use additionalSW xIV paper, Ifnet scary.

I alfinrithatthe numberofpe5ent meords reviewedshad be sufficientto assure adequate reviewof the rkiyslclanassietanfepractlce. Deviationfrom100% chartreviewwillrequireBoardapproval PRIORTOINIPLEMENUNGTHE NEWREVIEWPUN..

DO NOTSUBMWCHANGES]‘ÔPATiENTRECORDREVIEWPUN PRIORTHECOMPLETIONOP THEINIflALPERIODOP WE MEWSUPERViSIONAGREEMENT.

list flrst Mld7e NAME— PRIMARYSUPERVISING PHYSICiAN:

PRIMARY SUPERVISINGPHYSICIAN • SIGNAWRE

4 -“.. .SUB5TnUTE LICENSE PHYSIC PHYSICIAN lICENSE SUBSTITUTE PRIMARY PHYSICLNNAME; PNMAKY$UPBWISING PRACTICE lICENSE city prqvldedln ØurdiUáed Provide This policy fj. approval. The of deteof the. nd’ PL.EASK check REFUNOASLE. eppcdauon application temporadfr end PLEASE pLEASE LEAqE .. payment . application .. ; • the temperaty proof phydan . STATE armonaorder IAN while Submit . IsSURfiCS. . eppflUon IAJMDER NUMBEft Proof answers Canpielion Cared NUMBER: gnof SUPERVISING PMfl — NOTE: NOTE: ADDRESS: lràurthaor . ASS ASSTA1ff or process, Includes •- APPUCATION order ALLOW cornmenóe • SUPERVISOR’S SUPERVISOR peflomiing _._..___1Z1A___O insuranc&càrt*Itate of dii BOARD process, assistant HARRISBURG, authorization Email: ISTAW nt fee. OR asnant to ‘ThI LICENSED If for Regular This . wIJI cmfniional Upon the aD the ajdndlng TYPE of AT the PRIOR . retirned fee questions mqi5re a insurance becw -- NAME: many Boad practice P.[o.20X2649 ót-csteopathicgpa.gov UabilIty OF . APPLICATION 717.Th.dS5I osrrent PHYSICIAN Mach Board receipt LEAST physician cannot 1o. ALL NAME: Mailing - to OSTEOPATflflEbICINE PLEASE Items. of edditionel TO shelirequire p!cabon BY unflIdbyyou practice Insurance INFORMATION. to and theMe . Wake with the PA1TIOS.2541 - In provided of IIabWtv- be THE 120 - THE Issue must FOR accordarce B supporthig Failure coirect aesisbfitsOrvic!s ...“ Mdteaa supporting twwfeñed . chock comelefo flAW NOTE end Is OARD processing PENNSYLVANIA I_ .. . temporary coverage Include . IS bytes ,. insurance valid is . the to wdlteñ REGISTRATION appEcatn . oId FOR Dr FOR bank, provIde . applicant documents for doainentatton: with emplör money A . ISSUING-A to’ If application, the than - USE agreement. 1w 120 time. PHY the . PROCESSING another flrdless authodzauon the physIcian ccvamW one the wltten fonn one . days - order t6sUbmlt ONLY In . IICIAN .1,L pending . physician TD(*i or associated . . the . year with STATE . . appllcaflon mSm ONLY the agreement TEMPORARY payable of . BY.A h’ Commonwealth .. assistant’s all for mioinLnñ ASSISTANT 1mm the B

I. I I . I I board _._ of written to requested assistant 110W whIle OF BOARD the the mason practice. with PRIMARY Ii AS to . . . applltton following THE will is Ciwsiclan the !s - the data agreement amóónt the . STATE . Identical A name —______for Issue

w IrnnáIion ‘Commonwealth written - application OF WRrnEN 2. AWN ,, submitted SUPERVISING CANNOT non-paymunt. ..- NUMBER: PRAC’UCETELEPHONE Phil 97-3 Rmt or A Items SUPERVISING of OSTEOPATHICMED1CINE. and-IndIcate .. pocesaing BOARD a bicludlug for Pennsylvania. 2SDIN0ATHTHmDSmEn -.- 51,000.000.00 subtant ORIWTO agreement submifted later HARRISBURG, Courier _..n! all . will . Including cthinàt supervisors, and AGREEMENT PRATICE result authorizing . OFOSThOPATMC the 4 the

11&oa fe Your of DqBverv-Mdrfls through that with be là required .- PRACTIóE ins apIIcant . Pennsj$venla.’ of signebsma, being perccalnence PHYSICIAN mém cancelled r Proof S20O0 they -______denIal thIs submit PHYSICIAN PA the . - salf4nsumnc*, - tratuated fee. than are FINAL Ice6on, Di ., wishes of 4iiI physidan -. 17110 one rre’ Insurance cEovered dates, check tethporary six In be order apr4TlIon FEES A!’PROVAL mOnths ordaims dtged

[ to MEOICSE for Is and tie conunui A assistant your to under 6naI persona3y ARE. approval, coriplete must complete complete from (D1P2017) for made. receipt Board for this NOt any the the be to (0112017)

.. PENNSYLVANIASTATE BOARDOF OSTEOPATHICMEDICINE )

LISTYOURSPECIAL11ES: . I ynjft No ‘ DOYOUHOW HDSPffALSTAF PRIVILEGES?

IFYES,LISTHOSPITAI1S): I . I I

• I willdIrect slid exercise supervision over the hamad physician assistant in accordance with the rules apd regijatlons of the State Board of Osteopathic Medicine.

• I ved, that I have reviewed the Osteopathic Medical Practice Act and Regulations of the State board of Osteopathic Medicine.

• I recognize that I arr obligated to comply with nil paisions of the Act and Regulations Includingthose provisIonsthat require meto notifythe Boardof the termination ofmyagreement to supervise the physician assistant, nhvslclan • Irecognize that Iretain fullbrofessional and legal regislbKh.for thenerfcrmanceof the. assistant and the care end trsathierg ot1helhTcbn assMart’c batiets: ,, 1

• I ver%’that the sthtaththits in this application and written agreement’ale hue end correct to the best of my krtwiedge. informationend belief, 18 • Iunderstand that false statements era made subject to the penalties of Pa, C.S. §4904 rQlaung.b unawom falsWzaflon

• to authorities end may result in the suspension or revocation of mymgistrstion. • Iwillprovide all cubstithie supe’rvlslnn phyilclans with a eaoyotthe apprOved SuoMstnpwriften aoraement. • The, physician assistant Idertified in this sppffcallcn will only work with the primary supeMslng physician and histhet substitute physician assistant supervisor(s). • The physician essishint willcrly provide medical services to the patients under, the care of the primmy and subsUMe supervisor(s) and WILLNOT prnctle If ife supervising physician at an authocJted substitute supaMsot Is not available.

PRiMARYSUPERVISINGPHYSICIAN - (Printed Name): ‘ .__—______

‘ PRiMARYSUPVISUJG PHYSICIANSIGNATURE ..

•1 PHYSICIANASSISTANT(Printed Nra):______.. . , —

PHYSICIANASSISTAWrSIGNATURE: . .

PLEASENOTE: The .pdmarv suneNleor’s responsibilities include: •Providing a copy of the final Board ipproved written agreement toaII substitute supervisors. • Maintaining a cutrent IM of all locations where the physician assistant will perforM duties. . • Maintaining a current list of all substitute SUPerVISOrS u,fder which the physician assistant will work. .. Notifying the Board of Changes to the primary practice location utilizing a written agreement change forms . • Ensuring that the physician assistant will not practice without supervision by either the primary supervisor or an authorized substitute supervisor.

2 (0112017)

PENNSYLVANIASTATEBOARDOF OSTEOPATHICMEDICINE WRInENAGREEMENt

. Nn* NAME- PRIMARY SUPERVISINGPHYSICIAN:

• Lest Fit NAME—SUBBTffUTh

SUPERViSINGPHYSICIAN: . •

. Lest - Rit Midie NAME— PHYSICIAN ASS

•INSTRUCTIONS; Please provide the following Information(typed) forquestion 1 On A.6• * 1? sheets of paper and attach ththIs faint The Informationon this agreement must be agreed tt by nflsupwvfsts (primary and substitute).

1.• Describethe £unthonsItesi b be doläated ta tho physiciananisnt

2. Providethe detaL descdbingthe time,place and manner ofsupeMaionaiE thedcn you willpmde ihe pfrjcicianfisikmant Thctidlngthe frequencyotpemonni a3nWctwiththe physicianassistant -

3. II the physician asstwit wtl practice bi a hoepbi anWor asuiglceI center, provide the name and address of each hospbUswlcal Mer bebw. if more then three howfleiakurgIl enters, pIee providethN Tnfannami on a capable sheelof paper.

Nameof Hasp4taLiIni cent Mdmse —- - • -.

Nn M NeqIaaupMI a

Nwo. of Hcqui4aeI Mdia

Yea No 4. Wifithaphyskkn asaistait prescribe and sponsedrisgsAhe,apéutic davkes? J j Iiyes.-please ldenfltfl%4i)dicâLSgOnÔSofcontrolledsubataritta nay be pmscnbt and disipensed?

D None C Sl)edule If C Schedule III I] Sthedule IV C -Schàdule V

Ust be’owany spedflc dnjs that the pJiyelcienassistant WILLNUTbe permHtpdto preecdbeldispensS.

Proof of pmfesslcnal liabIlityInsurance cove,fle for the physician asslttant named above Yea No S. (51.000.000per occurrence or claims made) Is included wIththis written agreement appiicatIon.\

S (GIRD11)

PENNSYLVANIASTATEBOARDOF OSTEOPATHICMEDICINE

- eNO Lest First iMddle , NAME-PRIMARY SUPERVISINGPHYSICIAN:

Last . Mde NAMa-PHYStLAN ASSISTANT:

The supervising physician,whether primaryor secondary, must countersign100% of the aUant reàords completed by the physician assistant withinó reasonable the, whichshellEptexced days duringeach ofthe followingcoOs:

• The iirst12 months ofthe physicianassistanre pmWco post graduationand afterobtainingilcensure. • Thu Itmt12 months ofthe physicianassistant’s pmrMcaIna new specially. • The fimtS monthsof the physIcianassistants practice In the same specialty under a new primarysupervisor (unless,the new prImar’cuporvlsorwas registered as a cubsuwit supervisorforat feasts[xmonths under another writtenagreement).

INSTRUC1IDNS:Ityou eniwerYn InSeatienAynu do net end (a comprdssscdan a w... nwm Na hi Sec&nA ikenyoumustcenpiolaSoeticaS.’

Yes No I willcountersign 100% chaft 4Wew of the physician assislanrs patient remids withinthe raquñd ID day peod. -— ;fl ,_ — No

I have been reisIeredas a substiluta supervisorfur the above Identifiedphysician osaistants practice in the same specialty for at least six months and I Intend to deviate from the 100%diart review of the physician assistants patient records withinthe required 10day period?

Ifyou Intend to deviMe fromUie 100% chart review, providespeduip detailsbelow regarding howyou winselect patient records for reviewend withwhat frequencyyou IO review patient records. This Infonnationshould Includespecificssuch as the percentage ofpatient charts, specIfic typesor categodas of patient ses, etc. Use additionalSW xli” paper ifnecessary.

to the Iaffirmthat the numberof patientmcorth reviewed shall be sufficient assure adequate reviewof physician assbnt’s practice. pevLdcn tan 100% died re4iewwillrequ&eBoard ppprovalPRIORTO 1MPLEMEImNGThE NBc REVIEWPLML.

DO NOTSUBMITCHANGESTo PATIENTRECORD REVIEWPLANPRIORTHE COMPLETIONOF THE INITIALPERIODOF THE NEWSUPERVISIONAGaEu,r:

List .MJ4de MARY PERVISING

JI CM PRiMARYSUPERVISINGPHYSiCIAN . - - . -. ‘

4 UCENSE PHYSICIAN PHYSICIAN SUBSTITUTE SUBSTITUTE LICENSE C;ry PRACTICE LICENSE PRIMARY PHYSICIAN PRIMARY Erovided policy This purchased provide approval. The application the and temporadW PLEASE date checN REFUNDABLE. fgg. eath eppflcafion PLEASE of PLEASE • PLEASE payment • eppllcaffcn • temporary • • the proof of phyatcian while or STATE . Submit Issuance. application NUMBER: NUMBEk NUMBERr Proof answers Completion Concclfee. proof SUPERVISING SUPERVISING In money PUfl NOTE: ADDRESS: NOTE: ASSISTANT lnurance ASSISTANT of NAME Indudas process, order ALLOWAT APPLICATION commence SUPERVISOR’S SUPERVISOR performing lnsurancelcartlflcale of to authorization process, BOARD assistant HARRISBURG. of - Email:_st-osteopathicjpe.qov . ortie OR current - to for Tts. LICENSED II Regular THIS profrasianal wDiTeqL&e $. Upon at the or the a . of TYPEALL the PRIOR returned pencVng questions Insurance a NAME: below practice Soerd liabUIty many P.O. PHYSICIAN current OF APPLICATION 717-783-4958 LEAST Board physician zecelpt Aflach cannot NAME: Mailing to PLEASE OSTEOPATHIC Items. BOX TO additional of shall BY application unpaid practice Insurance INFORMATION. to and with the Make the in provided PA liability of 120 THE be Issue THE must requite 2649 accordance fee FOR Failure assistant a supporting correct supporting 17105-2649 Address transferred by DAYS comp’ete check NOTE; is BOARD and Last processIng Strait PENNSYLVANIA temcorarvaütharizatlenlopraclice incIud yew coverage by Insurence valid IS Is the to application c’nflten REGISTRATION the older FOR or FOR provide batik, serylces applicant MEDICINE documents for documentation. with emplbyerfor A mone9 ISSUING to the appUclion, Vthe than for USE agreement. 120 PHYSICIAN time. PROCESSING regardless another the - physician caverape - one the form wTitten days one to order In ONLY pendIng phyelclan or associated submit the A with year STATE morn applIcation. The ONLY ______the TEMPORARY agrewrcnf payable of Commonwealth BY assistant’s far cli minimum 61st. ASSISTANT from the Board a of written assistant: requested A new white OF Hiepheitcian BOARD the reason - with PRIMARY the AS - to THE application - following will Is th the amount agreement data f9: the STATE Identical A name for Issusa written Information WRITTEN AUThORW application OF commonweafth CANNOT submitted NUMBER: PRACTICE SUPERVISING First non-payment Rart ______FkI of A items of SUPERVISING OSTEOPATHIC and prosstng Pennsylvania. Including BOARD for - $1,000,000.00 2601 assistant agreement submitted letter HARRISBURG, Courier all indicate will including cannot AGREEMENT and supervisors, PRACTICE - NORTH result TElEPHONE authorizIng the To OF I.. the fee ______Your of through jvith that Ddlve,v Is be required PRACTICE OSTEOPATHIC In Penns}4vai1 applicant & sTgnahsrs, being per000urrenca PHYSICIAN a proof more THIRD cancelled they MEDICINE. $20.00 denial this submft the PHYSICIAN seiNnsuranea, PA 2oaq evaluated fee. am than FINSL Address application. of wishes of physician will STREET - 17110 one ______Insurance covered dates, check temporary six In be . order FEES ApPROVAL appIffon - months or - I charged to for MEDICINE —______dairns is and MW. continue A assistant under yàur tinal to personally ARE must complete approval, complete complete from (0 mede. lot aoa,d receipt for ma jhls NOT be any the the to 17) • (0112017)

PENNSYLVANIASTATE BOARDOF OSTEOPATHICMEDICINE

LISTYOURSI’ECIALVES; Yes No DOYOUHOLDHOSPITAl.STAFFPRIVILEGES?

IFYES LIST HOSPITAL(S):

• I willdirect and exercisesupervision over the named physician assistant In accordan wIth the aiIe end rogulaUons of the State Board ol Osteopathic Medicine. of • I verify that I have reviewed the Osteopathic Medical Practice Ad end Regulations the Slate Board of Osteopathic. Medicine. • I recognize that I api obligated to comply with all provisions of the Act and Regulations.incksdthg thoso provisions that require me to notifythe Board of the terminationof my agreement to supervise the physician assistant. • I recognize that I retain tuflyofesslonal and ieóal resconslbltv let the prnformance of the ehylclan ass!sbt and Viecam end treatment of the bhvsIcian assistant’s oatWnta. • I verti that the statements in this application and written amement are true and correct to the best of my knowledge, informationand belief. I understand that false statements are made subject to the penalties of 18 Pa. C.S. §4904 relatingto.unswom falsification to authorities and may result Inthe suspension or revocation of my regIstration.

• Iwill ptnylde all substitutesupeMslnp rhysiclens with a coØy of the approved supowicing written epmamonl. • The physician assistant Identified in this application will only work wIth the pilmary supeMsing physician and hisTher substitute physician assistant supervisor(s). • The ph&clan assistant wIUonly pmvfda medical services to the patients under the care of the piimary and substitute supervisor(s) and WILL NOT practice if the supoivisina physician or on authorized substitute supervisor Is not evelleble.

PRIMARYSUPERVISINGPHYSICIAN (Printed Nma)

PRIMARYSUPERVISINGPHYSICIANSIGNATURE;

PHYSICIANASSISTANT(Printed Name): Onto PHYSICIANASSISTANTSIGNATURE;

PLEASENOTE: The primary supeMsor’s responsibilities Include: • Providing a copy of Iho final Soard approved written agreement to all substitute supervisors. • Maintaining a current llt of all locations where the physician assistant will perform dutles. • Maintaininga current list of all substitute supervisors under which the physician assistant willwork. • Notifying the Board of changes to the primary practice location utilizinga written agreement change form. • Ensuring that the physician assistant will not practice without supervision by either the pdmarysupervisor oran authorized substitute supervisor.

2 (0112917) PENNSYLVANIASTATEBOARDOF OSTEOPATHICMEDICINE

. WRITTENAGREEMENT•

. Last Pir lAddie NAME— PRIMARY SUPERVISINGPHYSICIAN:

Last First NAME—$UBSTrTUTE SUPERVISINGPHYSICIAN: Isat RIM NAME— PHYSICIAN ASSISTANf:

INSTRUCTIONS: Please. providethe following Information (typed) for question.1 on 8.5 x 11” e.heBts of paper and attachtothis form. The Infounatlon on this agreement must be agreed to by all supervIsors (primary and substitute).

1. Describetheftincuonsftasks tobe delegated to tho physicianassistant.

2. ProvIdethe delals describingthe time,piece and mannerof supeMnton and directionyouwillprovidethe physician asslslant Includingthe frequencyof personalcontentwiththe physicianassistant.

3. If tiii physIcian assistant willpiacfice in a hospilsi and!or a suigloar center, provide the name and address ©feach hospfleVsurgicalcenter below. If morn.than three hcspltst&suTgicaicenters, pfrase provide this Informationon a separate sheet ofpaper.

Nameof HonpI8aurgIeaI CenWr däs - —______

Naa• of Nospkallligial Csitr Mdmsa

Uemeof Hospltailsw’gicalCenter Address -

No 4. Willthe physicianas&sthnt prescribeand dispense dwgs/therapeuuc deviee?

Ifyes, please IdenIl&whIchcategories ofcontrolledsubstances may be prescribed and dispensed?

Li None LI Schedule II Ci Schedule III Cl Schedule IV Q ScheduleV

LIstbelowartyspecificdwge that the physIcianassistant WILLNOTbe jiermittedto prescdb&dispensé.

Proof of professional lIabilityInsurance coverage for the physicIan assistant named abQIe Yes No 5. (SlOD0,O0Oper occurrence orcialme made) Is lncludedw[lh thIs written agreement applIcation.

3 (0112017)

PENNSYLVANIASTATEBOARDOF OSTEOPATHICMEDICINE

r—’.’ Ca”t, fl’ -‘ , - “ a— n.wt tri’%4 __ L. . List Fht Mlde NAME-PRIMARY SUPERVISINGPHYSICIAN:

, ddle NAME—PHYSICIAN ASSISTANT:

The supeMsing physician,whether pdmaiy or secondary, must countersIgn 100% of the patient‘recordscompleted by the physician assistant withina reasonabletime,whichshellnaexcccif jj da,s duringeach of the followingcasts:

• e fist 12months of the physicianassistants pmcce postgraduation and sits- obtntntnqllcsneure. • The first12monthsof thc’physldan assistant’s practicehi a new specially, • The first S months of the physIcianassistants practiceInthe same specialtyunder a tow pNrnarysupervisor (unless, the hew pdmay supenisor was registered as a substitutesupeMsorr at least sixmonths under anotherwrittenagreement),

PSTRUCIONS:ItyaunwotYssInSeedenAyoudenotneadta cea.pbteindent ltu mnswsrNoiniecllsnAtbnjou must completeBesteD.

Yes i willcounteralon100%’chartreview or the physician assistants patient rocodo withinthe required 40 day pedod.

Yes No I have been registerad 258 subsuMe supervisor (orthe ebov identifiedphysicianassisleoPs pmctlDtITT9 same specialtyfor at least six months and I Intuid to deviate fivm tile 00% chad revie’.vof the physician assistants patientrecordswithinthe requIred10 day period?

If you Intend to deviate from the 100%thaI review. providespecific details belowregardingh you willseIe patient rerds for reviewand withwhetfrequencyYouwinreview patient revords. Th’s Informationshould Irtiude speciricosuch as the peruentage of patientcharts,specifictypes ày categories of patientcases, etc. Use e4didonalS W’x irpaper. Vnecessary.

to adequate revIewofthe physician practice, Iaffirmttt the numberor patientrecords reviewedshall be sufficient assure aaeiitanta Dovinflopfthm lpp% cued review willrncu!re Boardapproval PRIORTO IMPLEMENTINGThE NEWREVIEWPUlL.

00 NOTSUSMITCHANGESTO PATIENTRECORDREVIEWPLANPRIORThE COMPLETIONOFTHEINITIALPERIOD OF THENEWSUPERViSIONAGREEMENT. —______

Lt First , fldJe NAME— PRIMARYSUPERVISING - PHYSICIAN: . . ,

‘ Oats PRIMARYSUPERVISINGPHYSICIAN SIGNATURE:

4- ACUPUNCTURIST 10Th1j2019 Evaluation,results: Board/Commission: OsteopathicMedicine License ¶‘pe: OsteopathicAcupuncturist.

Obtained By: Application . QQQ . CheckList Name J Instruciféns •.. All applications are processed inorder of submission, If this . applicationis not completed within th months, updates of certain sections andforsupporting documents will be required.If &pplieadon the applicationhas not been completedwithin due year fromthe

. date it was received, applicantswill be required to submit a new application (anothvrppJindoaprocessingjç) and supporting documents, as nçcessar

. ON REFUNDABLE FEE in the amount otjOinade ayab1e by àedWdebk card. lithe application has not been year fromthe date An licalian completed within one it was received, “‘ F applicants will be required to submita new application (another gpplicaffpn procesinguff) and supporting domimerns,as

. ecessnc All 4iOGOO health-related licensees/certificatehàlders and fim&al directors are considered“mandatoryreportcrs’ under sebtion6311 of the Child Protectite Servicts Law(23 P.S. 6311). ThereThre,

• . Ii persons applying for issUanceof ii initiallicense or certificate . . ftomany of the health-relatedboards (except the StateBoardof’

. Veteriàq Medicine)or from the State Board of Funeral Directdm are required to complete,as a condition olicensm’e, 3 hours of approved training by the Departmentof Human Child Abuse CE Services (DHS) . on the topic of child abuse recognition and reporting. AIer you

• havecompleted the requiredcourse,the approvedproviderwill elecfronic* submityo& name, date of attendance,etc. to the Bureau.For that reaspu, it is.irnperafivethat you register for the course usuj the informaiou.prnvided on your applicationfar liëensure/cerdficaion. A list of DHS-approvedchild abuse education providers can be found on the Departmentof Sate

. Website.

IM IwalflDlc ChecklAst Name Instructions ( j ii Provide a recent CriminalHistory Recordé Check (CHRC) from, the statepolice or otherstate agencythat Isthe oThcIal repository for criminal history record ififormatlon for ëveiy ‘ state in whichyod have‘lived,wôikçd, or completed professional . , training/studiesfor thepast five (5)years. The report(s) must be ‘ dated within 90 4ays of the date the application is submitted. For

‘ applicants 11ring,woildng, or completingtraining/studies in Pennsylvaüia,your CHRCre4uest will be automatically •‘ submittedto the Pennsylvania State Police Uponsubmission of : this application.ThePATCHfee will be included at checkout. YourPA CIJRC will be sent directly to the Board/Commission, Youwill be nofied if additional cfion is requfted..For, individualsliving,workhg,’or.completiflgftaining/stddies outside ‘ ,, Pennsylvania Check of dunng the past five (5) years, jwheu of obtaining individual state backgroundchecb, you may elect to provide BOTH a state CHROfrom the state in whichyou cunenfly.reside, AND your FBI IdentityHistory SummaryCheck, availableat bipilfwww fbi.gov/services/cjis/iden-hsthysuwmajy

‘ checks. please note: For applicantscunently living,working, or ‘ completing,training/studiesin California, Arizona, or Obio: Due to the laws ofthese stEtes,the Bçard is not an eliUiblerecipieniof

. ‘ CHRC’sor your CHRCwill notje issued to you for upload ‘tothe

‘ Board.Please obtain your Federal Bureau of Investigation (FBi) Identity History Smniniy Check, availableat the linknoted’

‘ above. Providean officialnofificafipnof informitiou (Self Query) from the NationalPmciiioner Data Bank. Pleasçrefer to the N?DB websie for additionhlinformation.’When ybureceive the a(Abflfl RCPO - “Res$ohseto your Self Quenj,” ton will needto upload it to your

‘ online application.The report will need to b uploaded, where

‘ prompted,in order to submit your application.

2(4 iwaimoie CheckList Name Instructions J j CompleteSection 1 of the Verificationof Education (Forth 2) and forwardto your school for completionof Section 2. The school must return the completed verification flrecfly tç the Board. Education AUdocuments must be in ENGLISH or an official translation Verification must be submlftedto the Board from an official translation : agency or professor of the language. The form will be

. available for download and prlñfiqg when the application Is submitted. Requestthat your school provide an official transcript directly, to the Board. If the official transcript does not provide detailed wformaton regarding the couzw attendedfrom which the Fducalion*l applicant’seligibility is determined,the Board retains the right to &anscrlpts requesta copy of the acuptmcmreschoolcurriculum: Au documents must be in ENGLISH or an official translation must be submitted to the Board from an official translation agencyor professor of the language. &equestthe NCCAOM or state Board office to submit the certifying examinationbores directly to the BoaM. The NCCAOM must also verify completion of the Clean Needle Technique Course. if the exam was not taken in English, auange rwTOEFL(Testof EngUih äs a Foreign Language) sdoresto be

• submitteddirectly to the Board. . Dontactthe licensing authorities of the states, territories or

• countrieswhere you hold or have everheld a license, certflcate, ,ermit registration or other authorizahonto practice a health j tlatedprofession (whether active, inactive,exphtd or current) and requestletters of good smndmgNenflcabon of hcensure m Standin g%. OG ‘ thatstate orjinisdicfion. The letter mustinclude the following:

• licenseissue and epirafion date, li6ensestatus (cunent or expired) and disciplinary standing. The letter(s) of good standing must be sent dfreétly to the Board. iou will need to upload, where prompted,proof of professional liabilityinsurance coverage through self-insurance,peisonally, purthased insurance or insurance providedby your employer for Walpractice theminimum amount of $1,000,000.ODper occurrenceor claims Insurance niade.This proof of insurance/certificate must include your name and Indicate that yàu are covered under this polièy while performing acupuncture services in the Commonwealth ofPennsylvania.

3j4 1WSI?2019 [_CheckList Name_jf Instructions Youwill need to upload, whereprompted, a current Cuniculum Vitaelisting fl petiods of employmentor unemployment (i.e., child rearing, research,etc.) from graduationfrom acupuncture Resume/Curriculum schoolto present. The list must be in chronological order, include the month andyear,andindicatethe state/territoryin which the

. employment occurred.The resume/curficiilumvitaewill need to be uploaded, in orderto sulimityour application.

4,4 idiaiioie Evaluationresults; floard/Coththisslon; OsteopathicMedicine Lcensc flpe: OsteopathicAcupuncturist Obtained By:Aplication

11 f Checklist Name ThsfrUcdans AUapplicationsare processed in order df submission, if this ‘ applidatiónis not completed Within six months, updates of certainsectic s and/or supportingdocum uts will be reqnirei If Applicadon the pplicaion has not been completedwithin one year fromt dateit was received, applicantswillbe required to submit a new

. application(anotherplicationprocessbgj) and nippirflng documents,as nçcessary.

• ON REFUNDABLE FEE in the amoant of$3&flfl made - j,ayableby credit/debit card. If the applicationhas not been completedwithin one year fromthe date it was 4 IIáti ii Fee received, aj,plicantswill be requirØdto submita new application (pâpther plicaflonprocessingjçç) and supportin;doniments, as . iecessaiy. BQ.ca Allhealth-relatedlicensees/certificateholders and fimeral directorsare considered “thandatoxyreporters” under secfloA6311 of the Child Proteofite Services Law (23 P.S. §6311).Therefore, ‘ all persons applyingfor issuance of au initial license or certificate from any of the health-rlated boarth (exceptthe State Board of VeterinaryMethàine) or from the State Board àf Funemj Directors axerequired to complete, as a conditionof licensure hours of approvedtraining by the Departmentof Human Seryioes (DHS) on the.topic of child abuse recogmton andreporbng. After you havecothpletedthe required course,the approvedprovider will submit your name, date attendance, BureamelectonicallS’ of etc. tà the For that reaspn it is.impenUve that ydüregister forthe licensurWceffificaffon,Acourse using the information providedon your.application for list of DES-approved child abuse educationproviders can be found on the Department of State

Websie. .

114 10131fl019

CheckList Name f Instructions Provide a recentCriminal History Records Check (CfQ from repositorythe statepolice or other state agency that is the official for criminal history recordhformaUon foreveiy • stateinwhichyou have lived, worked,or completed professional.

. training/studiesfor the past five (5)years. The report(s) hmst be datedwithin 90 days of the date the applicationis submitted. For applicantsliving,working,or cothpletingftaining/sthdiesin. Pennqlvaiiia, your CHRC requestwillbe automatically submittedto the PennsylvaniaStatePoliceupon snbmjssion of this application.The PATCHfee willbe includedat checkout YourPACNRC will be sent directlyto the BoardfCmmiiq. Youwillbe notifiedif additionalactionis required..For. individualslit’ing,working, or.complefingtraining/studies criminal Riston’ outside ofF lva during the past five (5)years,iniieu of obtaining .Cha k indMdpalstatebackgrmmdchecks,you lay elect to provide BOTHa stateCURe from the statein whichyou currentlyreside, ANDyour FBI IdentityHistory SwnmatyCheck, available at bnps://wwwfbi,gov/services/sjis/identityzhisthrv-summary checks.

Pleasenote: For applicants currentlyliving,working, or coçipletingtraining/studiesin California,Arizona, or Ohio: Diw tothe laws of these ststes, the Beardis not an eligible recipientof CMtC’s or your CHRCwill not be issuedto you for upload to the Board.Pleaseobtain your FederalBurau of Investigation (FBI) IdentityHistorySummaryCheck,availableat the link noted above. Providean officialnotification of informaiion(Self Qiery) from the NationalPractitioner Data Bait Pleaserefer to the Nfl)B website Databank Report for additionalinformafion.Whenyàu receivethe - “Respohseto yoUrSelf Quer” you will deedto upload it to your onlineapplication.The report willneed tobe uploaded, where rompted,in order to submit your application.

2M 1Q/31ZQ1S

CheckList Jnsfrucffons II r NamlJ CompleteSection 1 of the Verificationof Education (Form 2) and

. forwardto your school for completion of Section 2. The school

. must return the completed verification dfrectlx to the Board. Education AMdocuments must be in ENGLISU or an official translation Verification must be submitted to the Board from an official translation

. agency or professor of the laAguage. The form will be . available for download and printing when the application is ______subfflitted.

. Request that your school provide an officIaltranscript directly to

• the Board. If the official transcript does not provide detailed

. iiformatlon regarding the courses attended from which the Educaffpnal applicant’seligibility is determined,the Board retains the right to ‘franscripts request a copy of the acupunctureschool curriculum. AU documents must be hi ENGLISH or an official translation . must be submitted to the Board from an official translation ‘ - agency or professor of the language. Request the NCCAOM or state Board officeto submit the certifying examination scores dfrectly to the Board. The NCCAOM must also verify completion of the Clean Needle Exam Results Technique Course. If the exam was not taken in English, arrange fir TOEFLçrest of English as a Foreign Language) scores to be

. submitted directly to the Board. Contact the licensing authorities of the states,territories or

. counthes where you hold or have ever held a license, certificate, permit, registration or other authorizationto practice a health related’profession(whether active, inactive,expfrcd br current) d and request letters of good standmg/venficabon of licensure in Stau € g OGS1 ‘ that state órjudsdictioh. The letter must inlude the following: license issue and qpfrafio&date, lidensestaWs(current or

. expire4) and disciplinary standing.The letter(s) of good

• standing must be sent directly to the Board.

• srouwill need to upload, where prompted,proof of ptofesional

• liability insurancecoverage through self.iñsurance,personally

• purchased insurance or insurance-providedby your employerfor ialpracflce the minimum amount of$ 1,000,000.00per occurrenceor claims insurance made. This proof of in arance/cerdficate must Include your ‘ flUmeand indicate that you are covered under this pollky

. while performing acupuncture services in the Commonwealth of Pennsylvania.

3,4 lOflh/2010

J__CheckListName__j Instructions Youwill needto uplda4 whereprompted,a cunent Curriculum

. Vitaelistinga]!periodsof employmentor unemployment(i.e., childrearing,research,etc.)fromgraduationfromacupuncture Resume/Curriculum schoolto present.Thelistmustbe in chronologicalorder;include Vitae . themonthandyear,andindicatethestate/teffitoiyin whichthe employmentocaried. TheresumWcwxicuiumvitaewillneedto. . ,c uploaded,in orderto submityourapplication.

4,4 10t31a019 Evaluation results: Board/Commicsiont OsteopathicMedicine license Type: OsteopathicAcupuncturist Obtained fly: Application

Checklist Name] kstrucffons 1 AUapplications are processed in.ordcr of submission. If this application is not completedwithin six months, updates of certain sections and/or sUpportingdocuments will be required. If Application the application has not been completedwithin one year from the date it was itceivëd, applicantswill be required to submit a new application (another aplicafion processingjç) and supporting documents, as necessary. NCN REFUNDABLE FE in the amount ofØó made payableby credit/debitcard. If the.application has not beeh completedwithin one year from the date ft was receive4 A licafion Fee I! applicants will be required to submit a new application (another tuplication procesSing.fç) and supporting documents as - iecessaiy. $2Q 00

MI health-relatedlicensees/certificateholders and funeral - directors are considered “mandatoiyreporters” under section 6311 ofthe Child Protecifte ServicesLaw (23 P.S. §6311). therefore, all persons applyingfor issuanceof an initial license or certificate from any of the health-relatedboards (except the StateBoard of VetefinazyMedicine) or from the State Board of Funeral Directors are required to complete,as a condition of licensure,3 horns of training by the flepartment of Human Sentibes Child Abuse CE• ‘‘m (OHS) on the topic of child abuse recognition and reporting. After you

• iave completed the required course, the approvedprovider will electonica]JS’submit your name, date of attendance,etc. to the Bureau.For that reaspn; it is.imperative thAtyou register for the courseusing the informationprovided on your applicationfor licensure/certificatiozi.A list of DHSapprovqd child abuse educationproviders can be found on the Departmentof State Website. -______

1/4 iW3i&O1

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I, 1013112019 CheckListName Insfruèdons f II

, Youwillneedto upload;whereprompted a cuuent Curriculum . Vitaelistingd periodsof empIo3mentorunemployment(i.e., childrearing,reearch, etc.) fromgraduationfromacupuncture [I ume/Cuniculum schoolto present Thelist.,mustbe in chronologicalorder,include themonthandyear,and indicatethe stat&temtorym which the

, . employmentoccurred.The.resumç/amiaiilumvitae will need to beulcaded, in orderto submityourapplication.

4Th PHYSICIAN ACUPUNCTUEJST all

10/31/2019 Evaluaffonsesults: BoarWCOmmisilon:OsteopathicMedicine License 1’pe:tsteopathic.Acupunbturist• Obtained By: Application Qoao

CheckList Name . Instruciféns - An applicatidnsreprocessed inorder àfsubtission. If this . p applióafionisnot completedwithinthmonths. updates of • certainsectioz and/orsupportingdocumentswill be required.If &ppUcadon theapplicationhas not beencompletedwithin one tear fromthe dateit was received,applicantswillbe requiredto submita new .. ppliëation (anothcnppUcsdowpmcess1ng.f) andsupporthg . docurnenä,as necessary. - REFUNDABLEFEE in’the • ON amountoøCmade payable1y &edit/debitcard.if theapplicätiodbus nOtbeen completedwithifroneyear the dateit was received, Application Fee am plicants willbe:reqvirçdto submita new appiicafion(an6ther pJfcaffon$roces1ngfc)andsuporthgdocuments,as •. Al health-relatedlicensees/certificatehàlders and fànéra1 directorsare considered“mandatoryreporters”uhder-seefion6311 ofthe ChildProtectiveServicesLaw(23 PS. §631 1). Therefore personaapplyingfor issuanceof âp initial licenseor certificate

. . fromany of the health-ielatedboards(exceptthç Stateoard of’• VeterhiaryMedicine)or fromtheStateBoardof FuneralDireCWrS ! rc requiredto complete,as a conditionof licensure,3 hoursof qsprdved utg by theDepartmentof Human Services(1)115) Child AbUSC- CE onthe topic of childabijse pofflonaid reporting,Afteryou havecompletedthe rejuhtd course,the approvedproviderwill 1ecfronicafl’ submityourname,•date . of attádance, etc.to the . Bureau.!ForThatreaspn;it iiniperadvé.th youregisterjbr ae

p. courseusjn the informationp!tvided onyour applicationfor

. lióensure/cerffficudonA list.ofDHS-apprnvedchildabuse.

. eduoàdonproviders can be foundon the Department ofState ... Websift.

lid 1D131J20W CbeckffitName iniftucifons f Provide a recent Criminal HistoryRecordáCheck (CHRC)from

, . the statepolice or otherstateagenbythat Isthe official

. criminal bistory record • repository for information fortveiy

. - statein whichyouhavelived,workçd,or completed professional . mining/studiesforthepast five(5)years. The report(s)mustbe - datedwithin 90 daysofthe.datetheapplicationis submitted.For applicantsliving,working,or cothpletingtraininglstudiesin . ?ebnsylvatha,yourCHRCreiüest will be momatically submittedto thePennñylvaniaStatePoliceupon submissionof

. thisapplication.ThePATCHfee will be includedat ‘ checkOut. YourPACURe willbe Sentdirectlyto theBoard/Commission.

. Youwillbe notifiedif additionalactionis required.For. . . . individualsliving,w&dng.or.àompleffngtrainiñg/studiesoutside of Pennsylvamaduringthepast five(5) years, rn-lieu obtaining ChCCk of individualstatebackgrouhdchecks,you may elect to provide BOTHa state CIUtO from theslate in which yot currentlyrpside, .. ANDyour FBI IdentityUIStOIYS’irnmazyCheck, avafliMt at

. hjs://vw,thi.gov/sewicèslcjislidentity-Mstonj-summwy checks.

., Pleasenote: For applicantscinrenflyliving,working,or

. * èompletingtraining/studiesin California,Arizona,or Ohio: Due

. tothe laws of these states,theBoardisuot an eliElbierecipientof . - bHRC’sor yout CHRCwillnofle bsued to you for uploadlà the . . 3oard.Plàase obtainyour FederalBureau of Investigation(FBI)

. identity HistorySnmmaryCheclc available at the finknoted . v . , above. . . .• . - pj anofficialnotificationof information(Self Qizeiy)from . . theNational PractitionerData Bank Pleae refer to the N!’DB. websi for addifionMinfoimafion.When yOureceive the 0 aUib°-’flflfl ILVP•ft “Rèsyiohseto your SeWQuer),” you will needto uploadit toyour

. online application. Thereport w111need tObe uploaded,where

‘ ,rompted, in order to submityOurapplication. .

I .

10/3 QecWstNarne / Inircifons { Complete Section 1of the Verificationof Educafiôñ (FUrñ 2) and . fotwardtoyourschool tbr completion of Section 2. The school . . must return the completed verification .dhItCU3 to the Board.. Education 411documents must be In ENGLISH ‘or anofficial franslafion Verification mAstbe submittedto the Board truman offidal translation

. agency or profcssor of the language. The form will be iyailabie for downlqad and printing when thç appliâfion is •

. . . . . iubmitted. .

.. . Requestthat your schoolprovide an official franscrilitdireefix to . does •: the Board. if the officialtranscript not provide detailed . . infonnaticmregarding the COUrSeS attended from which the

. Educafional . .pplicant’s.eligibilityis detexrnined,the Board retains the right to franscdpts requesta copy of the aèupuncwrcschool curjpu,jjj. AII

. locuments must be in ENGLISH or in official franiladon “. . . . 4 . mist be submitted to the Board from an official fransladoñ

‘ . . agency or professor ofthe Janguige.. Requestthe NCCAOM ogstate Board office ksubmit the ‘ . certifjing examination scores directly to the.Boèd.Tbe CCAOM must ho verify completion of the Needle Fxa Results fl . ThthuiqueConrseiftheexamwasnottakeninEnglisb,airange

. . ForTOEFLfrest of En&ih as a ForeignLanguage).sëoresté be . ciihmitteddirectly to the BOard. . .. • .. Coñtat the liàensing authorities of the states, tenithrièsor .: .. countrieswhere you hold or have ever held a Jiceñsó,cdrtificate,•

. ermft, registration or otherauthorizafion’topracficé a health . relatedprofession (whetheractive,ipáôdy, expired or curient) aid request letters of good sffindmglvenficabonoflicensurem

4 4 fl OG hat state or.judsdicdon. The letter mustinclude the fbflowint .4. licenseissue andexpirationclaw,li&risestatus(ctnent or . 4 expired)and disciplinarystanding. The letter(s) of good

. itanding must be sent directly to the Board. 4

. . 4 hfgu to upload1whereprompted, proof of pmibssional . will need : lability insurance coveragethrough self.insurancc,personally 4 insurance & insurancoprovi4ed by yoUremployerfpr . . ufthased &Ialpractlce the minimum amount of $l,000,OQO.OO.peroccuheñcior clQhs Ehsurañce nade. This proof of Insurance/certificate must indude your . name and Indicate that you are covered under this polièy whileperforming acupundturè sçn*n in the Commonwealth - - 4.- : Pennsylvania. I totalt .

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to 4M 1013112019 Evaluation results Board/Commission: OsteopathicMcdióine.. License 1’pe: OsteopathicAcupuncturist Obtained By: Application

CheckList Name InstrUtfions Ii : All applicationsare processed in ordcràf submission, if this • appliàatiou is not completed within six mouths, updates of certaih sections and/or supporting documentswill be required If 4pplicadon the applicationhas not been completedwithin one year fràth the date it was ieceived, applicantswill be required to submit a new ippliqaffon (another an cafloanrocessingfg) and spbrthg Jowthents, as necessary.

. •‘ON REFUNDABLE flKJn the amountbS36UP made payableby credit/debit ôard. ffthftapplication has not been completed*ithin one year fromthe date ft was received, A II lien F licahtsWffl be required to submit.anewapplication (another jpjflCaffonproceingjç) andsupport{ugdocuments,as DCCCSS&3. Allhealth-relatedlicenseeskérdficate hbldemand fimeral ifrectors are conáidered “màdatozy reponãs” undet section 6311 ,f the Child Pmteetite Services Law (23 P.S.§631 1). The efore, all persons applying for issunce of an initial license or certificate fromany df the health-rdated boards (exceptthe Stte Board of . VeterinaryMedlélne) or from the StateBoard of Funeral Directors. are requfrödto complete, as a conditionof licensuro 3 hàurs of approvedtraining by ØieDepartment Child use of Human Services (DJjS). on the topiö of child thuse recognition aridreporting. After you havecompletedthe required course,the approvedpr vider will : e1ccfronicall submit your name, date df attddance, etc. tothe Bureau.For thatreason, ft isiniperative that yorkregister forte courseusing the information provided on your • : application for licensure/ceriffleafiornA.list of 1)115-approvedchild abue e4ucaffonproviders can be found on the Departmentof State Website.

- 114 tDI3IIZOW {_Checklist Name_1 Instruèdons roride a recentCñminalHistoiyRecordsCheck(CBRC) froni

• the statepolice or other state agencythat is the official repository ft criminal history ncord.Informauon Threvery state in :whichyod have lived, worked,or completed professional. years.The . trøiing/studiesfor the past five (5) report(s) must be applicantsdated within 90 days of the date theàpplicàffonis submitted. For living,working, orcothpletng.taining/studics in Pennsylvania,your cimcrecuüst will be automatidally

. sibw4tted to the Pennsylvania StatePolice upon submission of his application.ThePATCHfre wilibe includedat checkout four PACTJRCwill be sent directlyto the Boar&Commcsion. Youwillbe nçbfied if additionalactionis required..For. living,working orcompletjng training/studiesoutside criminal individuals Chk of Peunsylvaniaduringthe pt five(5) years,inhicu of obtaining ... indMdui statebackgroundchecks,you nay elect to provide .‘ BOTH a state CHRCfrom the statein whichyou currentlyreside, Symmmy . AND your FBI Identity ilhitory Check, available at jvj’vtgov&rvieskjWidenthy-history-summaxy

• . checks. . .

note:For applicants currentlyliving,working, . Please br . coplethgflining/studies in California,Arizona, or Ohio: Due o the lawsof these States,the Boardis not an eligible recipientof : CHRCs br your CHRCwill notJe issued to you for upload lo the Board. Pleas obtainyoUrFederalBurçauoflnvesdgation (FBI) IdentityHistory Snrnmaly Check; availableat the link noted

3bVe. . -. Providean officialnàfffication of inñflaiion (Self ieiy) from the NationalPm4itionerData Bank.Pieasçreferto the NDB . . websitç oradditional infoimation Whenydureceivethe Databank Report - “Respohseto YOUr Self Quer” youwill needto uploadit to your

. Dnhineapplication.fle report will need to be uploaded, where in to submit.yow applicadon. ptompwd, ordr I

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agency must

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.414

D 1013112019 Evaluadoitresults: floard/Commicslon: OsteopathicMedicine license T’pe: Ostopathô Acupunetwist Obtalned.By; Application uisiI1O2- . CheckLlstName j( In&ucfious

. Afta*licafions are processed imorderof subitlision. if this . aplicaion is not completed within six months, updates of . xflain scffons and/orsupportingdoqumentswill be röqufred.If Application datethe application has not been completedwithin one yeas Atm the. it *as rèceivëd, applicantswillbe required to submita new

. application(suother appilcadon processintfr&) and supporting

.. . .. documents,as necessary. REFUNDABLE FEE in th&amoimtof made . ON $SeeU,

... . ayable by credit/debit card. if the applicationhas not been omp1eted within one year from the date itwas received, if°“ aplicants will be required to submita nw application (another . . wplkaifoprocesstngjcg) and supporting documents, as aedessaty MI VaO cc health-relatedlicensees/cer6flcat holders and Thneral

. directorsarc considered “ztandatoryreporters” under sàction0311 of the Child i?rotéètiveServicesLaw (23 P.S.§6311). Therefore, . all persons applying for issuance ofan iniflaflicense or certificate

.. from any of the health-related boards.(except the Stat&Boardof or the.State • VetàrinazyMediciñe) from Board of Funeral Directors .. . ire required to complete, as a conditionof lice isure, 3 baths of

- approvedtrainingby the DepartmentCfThmnn Seryices (1)118) Child Abuse CE on the topic of child abuse recognitionand reporting. After you

• save completedthe required course,the approvedprovider will. e1ectronicaJl sub it your name, date of attendance,etc. to the

. Bureau.For that reaspn; it is.imperativeihat you register foEthe •. . .

. ourse using the itfoimaflon provided on your applicationfor • [icensure/cerfificaifOn.A list of DHS-approvedchild abuse

• educationproviders can be found on the;DeparUnentof State Websile.. ..

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For

of —I 10131a2019 CheckList Name Instructions J, II

. . Complete Section 1 of the Vedficàfioñ of Education (Form 2) and forward to your school for completion of Section 2.The school aiust return the completed veiiflèatien ‘directix to the Board. Rducadon All documents müstbé in ENGLISH or an official traislafion. Veilficadon must be submitted to the Board from an official translation

. agency or professor of the language. The form will be available for download and:pri fing when the applic Honis

. rnbmiftéd

.. - Requestthat your schoolproyide an dificial transcript directix to the Board. If the official transcript does not provide detailed

. Lçformationregarding the courses attended from which the Educational 3pplicant%eligibility is-determined,the Board retains the right to Transcripts requesta copy of the acupunctureschool curriculum. AD . documents must be In ENGLISH or an official trflnslaflon • must be submitted to the Board from an official translation agencyor professor ofthe language. ‘ Requestthe NCCAOM or stateBoard office tosubmit the . cert g scores directly to the Board. The Enin NCCAOM must also veflê completion of the Clan Needle RSId TcchniqueCourse. If the examwas not takenin English,arrange ; :

• for IOEFL(Test of Englishas a ForeignLanguage)scoresto be

• nibmitted directly to the Board.

• Contact the liaensingauthoritics àfthé states,territories or

. èounfties where you hold or have ever hçld a license, certificate, permit,registration or other authqrizaflouto practice a health belatedprofesion (whetheractive, inactive, expired ôi cun’ent) I andrequest letters of good standmg/v.enficahonof licensurein Standin “ “ ocs’‘ thatstate orjuiisdicfion. Thiettc mustinclude the foJlowing:

. . licenseissue andexpirationdate,lidense•status(current or expired) and disciplinarystAnding.The letter(s) of good standing mUst be sent dfreátly to the Bàard.

. Youwill need toupload, whereprOmpted,iiroof of professional

. liability insurance coveragetlfroughself.inthiranne,personally ptuohasedlnsurance or insuranceprovided by your employerfor Malpractice ihe minimumámount ofSl,000,000,00 peroôcunenceor claims Insurance made.This proof of Insurance/certificate mustincludeynur . name and Indicate that you an covered under this pollèy

. while performing acupuncture services In the Commonwealth

. if-Pennsylvania. .

3M •

1Q1a112019

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e .

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4,4 RESPIRATORY THERAPIST 10(3112010 Evaluationresults: BOard/Commission:OsteopathicMedicineS. License 1)’pe:OsteopathicRespiratoryTherapist Obtalnçd By: Applicäffon.

hecListName Instructions U

.. If this applicäfiQiisnot completed.withinsixmonths, certain updatesof sectionsof the applicationandsupportingdocuthentswill berequired.If appil able,backgroundcheck.documentscannotbe olderthan90 daysfromthe date ofissuance.Kths applicationis 4pplicadon nOtcompletedwithinoneyear, youwiljbe requiredto completea newapplicationandiesubmitthe applicationfee:Youmayncft ractice in the Commonwealthof Pelinsylvaniauntil you.have .. bàénissueda licenie, certificate,registration,permit,or -. - authothation. ppJ °“ n applicatioñfeeof$ZetUGlsréqujrçd.Pleasenotethat allfees [arehon-reThndab!e. *100-00 Allhealth-relatedlicensees/certificateholdeñ andfuneral ofdfrdctor areconsidered“mandatoryreporters”under section6311 the ChildProtectiveServicesLaw(23P.S.§6311).Therefore, allpersonsapplyingforissuanceof an initialliceñsëor cerdficaie fromany.of thehealth-relatedboards(exceptthe StateBoard of VeterinaryMedicine)or.from the StateBoardofFuneralDirectors arerequiredto complete,as a conditionof licensure,3 hoursof approvedtrainingby theDepartmentcfHuman Services(DHS) Child AbU onthe topicof childabusereCognitionandieporting.After you havecompletedthe requiredcoursç,theapprovedproviderwill elecftdnicall submityourname,dateof attendance,etc. to the Bureat.Forthatreason,it Is imperativethatyouregisterfor the öourseusingthe informationprovidedonS’burapplicationfor

. licensurc/óeftfflcatidn.A list of DHS-appfcivedchildabuse educationprovidersöanbe foundontheDepartmentof State ,______Website.

113 1013112019 CheckList .InsfrucffOflS f Name I - &ovid&a recentCriminal HistoxS’Records Check (CHRC) from the repositorystatepollépor other state agency that i the official for criminal history record information for every . state in which you have lived, worked, at completed prossioiiaI

. framing/studiesfor the past five (5) years. The report(s) must be dated within 90 days of the date thá application is submitted.For .

. * applicaits living,walking, or cdmpleftnglnininstuffies in

. Pennsylvania,your CHRCrequest will be automatically

, submittd to the Pennsylvania StafePolicüupon submission of

•. this application.The PATCHfee wil4beincludéd at checkout YourPACHRCwill be sent directlyto the Board/Comniisjon. Ynuwifibe notified if Additionalaction is reqUired.PoT Criminal ,,‘, individuals livmg, working,or completingtaining/sttidies outside Pennsylvania past five (5)years, Ch k of dunngthe in lieu of obtaining mdwidual state backgroundchecks, you may elect to provide 30Th a state CHRC from the state in whichyo’ucurrently reside, : AND your FBI Identity History SnmmnryCheek, available at ps://www.fbi;gov(services/cjis/identityrhistoxy-sujmnar3i: . Dhecks;

, Plese note: For ajplicants currently living,working, or . . completingtraining/studiesin Califóti, Arizona, or Ohio:Due a the laws ofthese states, the Board is notan eligible recipientof CIifiC’s or your CHRC will not be issue4to you for upload to the

. Board.Please obtain yo* Federal Bureau of Jnyestigaffon(FBI) IdeutiWHistory SummaryCheck, availableatthe link noted above. Providean officialnotification of information(Self . Qiiètyfr6m. . the NationalPractitionerData Bank. Pleaserefet tOthe NPDB Datàbankfle ?vebste1kwadditional information.Whenyou receive the ‘) ‘Response tóyour Self Quci’,” you will needto upload itto your . I :nlinc applicaffon. The repqit will nçd to be uploaded1where prompted,in order to submityour aiplicafión. Forwardthe Veñflcafionof Educatidn ibrmfo your ichàolknivemity tçcomplete. Youaré onlyrequired to verify the Mn •ñ Levelof edpcation eompleiedwhich qualifiesyou for this veri ca on licexise.The school must return the completed verificadon

. roimdirectly to the Board, Exam Results Contactthe NBRC d aimn for your “credentialverification” . Ni h:tint &eit1ytn4he Rnnrfl -.

213

I tO31l2Ol9

(heckList Name . Instructions .

. Contact the licensingauthoHilesof the states,,territories or

. counties where you hold or have ever held.a license, certificate,

, registration or other authorization to practice a health ... . ermit, . relatedprofession (whethà active,liactive, expired or current) an4 request letters of good standing/verificationof hcensure in Staüdlng OGS ‘ thatsWe orjurisdidtion, The Jettermust include the following: • xpired)Rcenseisse and,expirationdat,.license átahis (current or and discipliuiaiystanding. Thelefter(s) of good itanding must be sentdlrectly to the Board. ?kase tpload a CurriculumVitae/Resume listingaMperiods of , . einploymcnt or.unemployment(i.e., child rearing, research, etc.) from graduation from your highest level of educationto present ‘Resume!CurHculum (theeducafion ëompletedwhich qualifies you for thislicense).

Vitae . Thelist must be in chronologicalorder, including the name, city

, andstate of the emploS’er,dates of employment or advanced

. education/fraiñing(includethemonth and yen), and d&ripflon . f the practice activity. 1013112010 Evaluation results: Board/Commission: OsteopathicMcdicine License Type: OsteopathicRespiratory Therapist Obtained By: Application.

CheckList Namej Instructions ..

• if thisipplication is not completedwithin six months, updates of certainsections of the applicàtián and supporting documentswill berequired. if applicable,background check documents cannotbe olderthan 90 days from the date of issuance. It this applicationis Application iaOtcompleted withinone year, you will be required to completea new application and resubmit the application fee. You may not practicein the Commonwealthof Pehusylvania until you.havó

• beenisued a licene, certificate,registration, peimit, or

. authorization. An application fee of$3êWTh réquiréd. 4ppbeafton Please note that all fees i non-refimdable. 4H0. 00 Mihealth-related liceñsees/cèr’dficateholdeñ and fimeràl directo±sare considered “mandatoxyreporters” under section 6311 of thc Child Protective Services Law (23 P.S. § 6311).Therefore,

• allpersons applying for issuanceof an initial license or certificate fromany.of the health-relatedboards (exceptIhe StatbBoard qf VeterinaryMedicine) or from the State Board of Funeral Directors arerequired to complete,as a condition oflicensure,3 hours of

A approvedtraining by the Department.of Hnman Services Child fl bUSC CE (DHS) onthe topic otchfld abu.e recognition and reporting. Afteryou havecomp1eted the required course, the apwved provider will electronically submityour name, date of attendance,etc. tothe Bureau.For,that reason, it is imperative that you Uourse register for the using the informationprovided on S’ow‘applicationfor ficexisure/certiflcaffou.:ducaUon A list of DHS-approved child abuse providers can be found on the Department • of State - Website.

113 tOflhI2ClB Checklist Name — Insfructions • Provide a recent CrimiiinlHistory Records Check (CfUtC) from the t* police orother state agencythat is the official • repository for criminal history record information for every state in which you.have lived, worked QEcomjiletedp±ofessional Iraining/stodiesfor the past five (5) yearn.The report(s) mustbe dated within 90 days of tle date the application is submitted. For applicaiitslMñ, working, or completingtraining/studies in Pennsylvnnhi.your CNRCrequest will be automafidally submittedto the Pennsylvania State Policeupon submissionof tis application.The PATCHfee will l?eincluded at checkout

. YourPACBRC will be sen; directlyto the Board/Commission. Youwillbe notified if additional action is reqàfrc& For individualsliving working, or completingtraining/studies outside C1 of Pennsylvaniaduring the past five (5) years, rn heu pfobtammg

check. individual tate backEound cheth, you may elect to provide

. BOTh a state CBRC from the statein which you currently reside, ANDyour FBI Identity Histoiy SmnniaryCheck, available at Lftps:I/vvwwJbL’gpvIsen4ces/cjis/identiPJ-history-summaw checks.

Pleasenote: For applicants currently living,working, or cdmplethgfrainlig/studies hiCalifornia, Mzona, or Ohio: Thie o the laws cSfthese states, the Board is not an eliuible recipient of

‘ CIUWs or your CHRC will not be issued to you for upload to the •• Board. Please pbtain your Federal Bureau of Inyestigaflon (FBI) EdenffQThstoxySiimmnryCheck, availableat the link noted above. Providean official notification of infonnation (SilfQuSry) from the NationalPractitioner Data Bank. Pleaserefet to.the NPDB websitefor addi ional informtion. When youreceive the Databank. 11 t ‘RespbEsetóyour Self Queri’,”you willneed to upload it to your online application. The reportwfflieed tobe uploaded, where ‘. rompte4, in order to submit your application.

Forwardthe Vedficafionof Educa&n form to your - sbhàoYuniversitytç oomplete.Youare.onlyreqüfredto vthtr the [eyel of edpcation completed which Verification qualifiesyou for this Licenäe.The school must return the completed verification directly to the Board, Bxam rnsults fCdntactthe NBRC and arráge for your “credentialverification” fr)acPnt1h*.rt1ytnt1ieNnrd a 1013112 Ia

CheckList Name Instructions II

. Cónth the licensing authorities ofthestafes, terñtories or countrieswhereyou hold or have-everheld-alicense, certificate,

. permit, registrationor other authorizationto practice a health

•. elated profession (whether active, inactive, expired or current) - and request letters of goDdstanthng/venfieauon of hçensure in Standin g “ ‘L o”‘‘ that slate orjizisdicfion.The letter piust include the following:

. licenseissue an• thcj±affondate, license ñtatus(current or’ - - expired) and disciplinarystanding. The letter(s) of good

. standing must be sentdirectly to the Board. - Pleaseuplind a Curriculum VitaeiResumelisting all periods of

• employmentoxuáemployment (i.e.)child rearing, research, etc.) . from graduaffon from your highest level of cducØion to present Resume/Curriculum (the educationcompleted which qualifiesyou for this license). Vitae The list.must be in chronological order,includingthe name, city

and state of the employer, dates of employmentor advanced - educaffon/traithg (includethe month and year), and description • activity. - f the practice

SM 10131fla19

Evaluation results: - Board/Commission: OsteopathicMedicine Liceáse Type: OsteopathicRespiratory Therapist Obtained By: Application. IV I)2oa CheckList Nathe Instructions TIthisapplication is not completedwithin sixmonths, updates of certain sections of the applicationand supporting documents will

• be required.If applicable,backgroundcheck documentscannotbe older than 90 days from the date of issuance.If this applicationis Appllãffon not cothpletedwithin one year,you willbe requiredto completea

• aewapplication andresubmit the applicationfee. Youmaynot ,racffeein the Commonwealthof Pennsylvaniauntilyou have ieen issued a licenà, certificate,rcgisftafton,permit, or

authorization. - An applicationfee Pleasenote An llcation Fee of’$3tOOi jq$re.. that all fees ° arenon-refimdable.

• All health-relatedlicensees/certificateholdeâ andfimeml lireetors are considered “mandatoiyreporters”under section 6311

• of the ChildProtective ServicesLaw (23 P.S.§6311). Therefore, all pextons applying for issuance of an initiallicerthdor certificate from anyof the health-telated boards (exceptthe State Boardof VeterinaryMedicine)Orfromthe StateBoardof FuneralDirectors arerequiredto complete, as a condition of licensure,3 hpursof - approvedtrainingby thô Department of HumAn Child Abuse Services (DHS) on thetopicof childabuserecognitionandreporting.After you have completedthe requiredcourse,the approvedproviderwill elecfronioaUsubmityourname,date of attendance,etc.to the Bureau.For that reason, it is imperativethat you registerfor the course usingtheinformaflonprovidd onS’oirapplicationfor lieensur&cerfifióadon.A list of DHS-appmvedchild abuse educationproviderscanbe found on the Departmentof State Website.

113 13112019

‘ rcheckLlst Narnç_J Instructions Providearecent Criminal . HistoryRecords Check(CNRC from the statepolice or other state agencythat is the official

. rtpothory for criminal history record Information for.eveiy

. thte in which you have lived, worked, or completed professional

. . raining/studies for the past five (5)’years..The report(s) must be. •: datedwithin 90 days of the datethe applicationis sUbmitted.For

• applicaatsliving,working, or cotiplefing fraining/smdies in . Pennsylania, your CNItC requestwill,be automatically iubmittedto th Pennsylvania StatePolice upon submission of . this application.The PATCHfee wil!be included at checkout YourPACHRCwill bó sent directlyto the Board/Commission. ‘ Youwill be notified if additionalaction,is required. For Criminal IIISthfl7 individualslivin working, pr completingtraining/sthdies outside of?ennsylvama dunng the past five (5) years, in lieu pfobtainrng . c .. xzdiw4ualstate background checks,you may elect to provide 30111 a state CHRC from the statein which ythi currently reside, . 3ffps://www.fbL’govkeP’ices/cjis/idenfity-hjpy-surmry.ANDyour FBI Identity History SummaryCheck,available at

. phecks.

lease note: For ajpiicanis currentlyliving, working, or . Qomplefingftabiing/studies in California,Mzoha, or Ohio: Due to the laws of these states, the Boardis not eligible recipientof’ . t CBR&s or your CIJKC will not be issued to you for upload to the

. . 3oard.PleaAeobtain your Fedeni Bureau of Investigation (FBI) [denfiti . History Summary Check,avaiLableatthe llk üoted • ‘ above. . rotide an official notification of information(Self Query) from. theNationalPractitioner Data Bank. Pleaserefer to the NPDB websitefor a4thflonalinformation.When you receive 1)ata b Bflk Re the “RespbñsetOyoUtSelf Quei” youwill need to uploadit to your . onlineapplication. The repons4ll need to be uploaded, where ,rompted,in order to submit your application. ‘ , Foiwañlthe Verificationof Educationformto your Ed sthàolhmiversity to complete. Youare.onlyrequfred to vedfy the . Leyelof education complefedwhichqualifiesyou for thls Verifi . .: License.The school must return the eampleted verificalion form directly to the Board.. exam Results Contactthe NBRC and arrapge fOryour “credentialvedficafioj’ tn 1’ qnt 1irrt1y fnthe flnit,q

zra’ 10131120(9

Checklist Name j Instructions . Contactthe licensingauthorftièsof the states, . territories or countrieswhere you hold or have ever held a license, certificate,

. ,ermit,registration or other authorizationto practice a health

. relatedprofession (whether active,inactive, expired or current) . andrequest lettersof good standing/verification Standing (LOGS) of licensure rn that stateorjurisdiction.Theleffer must include the fpflowin: licenseissueand,expirationdate,.licensetatus (current or expired)anddisciplinarystanding. The letter(s) of good standing must be sent’dlrecUy to . the &ard.

• Pleaseuploada CurriculumVtaelkes ne lifing all periodsof employment1wunemployment(i.e., child rearing, research etc.) fromgraduation fromyourhighestlevel of education to present Resume/Curriculum (the educationcompleted which qualifiesyou for this license).

Vitae . Thelist must be‘inchronological order,includingthe name,city

. andstate of the employer, dates of employmentor advanced

. education/training(include the monthand year), and description lcfthe practiceactivity.

Wa ATHLETIC

TRAINER IWSWOI9 Evaluation results: Board/Commission: Osteopathic Medicine License Type: Athletic Trainer Obtained By: Application - o o CheékList Name jj listhictions. If this application is not complEtedwithin sir mons; updates of certain sçctions of the application and thxppqrtingdocuments will be required. If applicable,background check documents cannot be older than 90 days from the date ofissuanpe. if this appUcationIA Application ot completed within oneyear, you will be required to coàpletc a new appfleaflôn : and resubmit the appflcajion fee.You may not

. practicelii the Commonwealthof Pennsylvania till you have beenissued a license, certificate,;egisfration, permit, or , authorization.

IA [Anapplication fee of 0 is required. Pleasenote that all fees pfl licali011 Fec nonrefimdable. 4 AUlicaith-rélaled licensei/beitffi cate hàlden and fimetul directors are considered “mandatozyreporters” under section 6311 of th&ChildPmtecti’,e ServicesLaw (23 P.S.§631 1).Therefore; . allpersons applying for isMianceof an inithI license or certificate ftom any of the health4elated boards (except the State Board of . VeterinaryMedicine) or fitm the State Board of Funeral Directors are tequired to complete, as a condition of licensure,3 hours of aprovéd by Child Abuse CE training the Department of Human Services (1)115) , DU the topic of child abuse recognition andreporting. After you have completed the required course, the approvedprovider will elcctronicallysubmit yourname, date of attëndance etó.to the Bureau.For that reasdp, it is imperative that you register for the course usingthe informationprovided on your applicafionfor . licensure/cerfificaffdn.A list of.DHS-appmved child abuse education provi&rs can be found on the Departmentof State Website. .

1/3 1O!31f019

Cbec!cLlstNanir. -. - Instructions Providea recentCriminalHiitoiy RecordsCheck(CHRC)fràrn thestatepoliceor otherstateagencythat ii the official

. repository for criminal history record Information forevery whichyouIi ye lived,worked,or completcdprofessional. $ state.in ñining/studies forthepastten (10)years.The repoft(s)mustbe

. datedwithih90 daysof the dAtethe applicationis submitted.For applicantsliving,worklnj or comleflng training/studies.in

. Pennsylvania,yourCHRCreqUestwill be automatically

. submittedto the.PennsylvaniaStatePoliceupon spbmissiônof -

. thisapplication.ThePATCHfee willbe includedat checkout . YourPACIffiCwillbwsentdirectlyto the Board/Commission.

. Youwill be notifiedif additionalactionis re4ithed.For Criminal hzdividuajslMnj working,or completingfrab in/studies outside Check of Pennsylvania dunngthe past ten (10) years, m lieu of obtaining . noTHbdMdual statebackgroundchecks,you may electto provide. a stateCHRCfrom the sthtein whichyou currentlyreside,

. A}IDyourFBI IdentityHistorySumtharyCheck, bSps:J/www.Thi,goWservices/cjis/idendty-histoiy-summatyaváilabl at

. ±ecks. .

Pleasenote: For applicants currentlyliving, working, or. cOmpJetingflinin Wstudies.iñCalifornia,Arizona,or Ohip:Due

, to.the 1awsofthesestates,theBoardis not an eligiblerecipientof CIWC’sor your CNRCwillnot be •1 issuedto you foruploadto the . Board;Picase obtainyotfrFedçmlBureauof.Investigation(FBI)

. . Menthy,HistoiySiUnmaryCheck,availableat the link noted

. above. .

• Providean oMcialnoffficaffon.ofinfOrthaion(SèWQueiy)from theNationalPtacfifionerDataBank.Pleasereferto the NPDB for additionalinfoniaffon.‘When Databank Report websitó you receivethe “Respcnseto ydur SelfQüeiy7you will needto upload ‘ ittoyour . onlineapplication;Thereportwilliwedtobe uploaded,where prompted,in orderto submityour application. • IContaCtthe BOCandrequestan officialveffficáfionof bffi Ilexaminationregisfratioiletterto be submitteddirectlyto the . ‘ jfBoard.Thisis onlyrequiredif you areapplyingfora temporary framerlicense. .

2S 10/31/2019

Name Jj Instructions rc’cat I’

‘ Contactthelicensingauthorifiçs.ofthe states,territoriesor , dounftieswhereyouhold or have everheld a license,certificate,

. permit,regisfrationor other authoHzatidnto practicea health .. relatedprofession(whetheractive, inactive, expiredor current) andrequest letters ofgood standmgfveuficauon of licensure in g OG1 “ that stateorjUrisdiction.The letter must include the following: licenseissue and expiratiàndate,license status (current or expired) and disciplinarystanding.,The letter(s) of good standing must be sent directly to the Boari National Contactthe BOCand request an official verificationof

Certification - certificationletter be sent directly to theBoard. -,

, CompleteSection 1of the Verificationof Graduation from an

. ApprovedAthletic Trainer Program Form and forward to your Record of atffleffc.frainereducationprogram for completionof Section Graduation 2. The school must return the completed verification directly to the Board. The form will be available for . download and

- - printing when the application is s’41E1tt4.

.. Pleaseujiload a CurriculumVitae/Resumelisting 41periods of . . employment,or unemployment (i.e., chjldrearing, itsearch, etc.) ftomgraduation from your highest level of education to present Resum&Cunlculum (the education completedwhich qualifiesyou for this,license). Vitae - Thelistmustbe ib chronological ordex including the name, city’ and’stateof the employer,datesof employmentor advanced

. education/training(include the month àdyg), and description • of the practice activity

3,3 r )

ionmolo

child

4pplfradon

License

Obtained

BoaidlCommlssion:

Evaluation Applicadon

H •. .

. CheckList . . .,

‘ A.

Type: fly:

. résifits:

Fee CE ..

Name

Application AthleticTrainer . - . ..

ethcationproviders

licomsute/catification.

courseilsing

Webith.

electronically

are

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have

approved

all

Osteopathic

directors All

Veterinary

authorization.

been

not

older

practice

bt certain

the

persons

this

tequired

required.

health-ielated

application

completed

application

any

issued

Child

than

topic

application

For

sçctions

are

training

Medicine)

applying

the

that

the

Medicine

Piotective

the

considered

ffpp1icable,

submit

license,

days

child

complete,

Commonwealth

within

fee

health-related

the

infbrmation

reason,

andráubmit

licensees/certificate

the

required

toni

can

abuse

for

the

your

not

one

certificate,

application

Services

issuance

from

“mandatory

Pepaflthent

list

the

completed

name,

year;

recognition

found

baokgroiirid

Instructions

imperative

con,

provided date

condition

the

boards

the.applic4ion DHS-approved

requfred

you

Law

date

clan

registration,

State

Pennsylvania

and

issuance.

within

the

will

reporters”

(23

(except

holderà

and

initial-

suppqrfing.documents

Board

check

that

Human

Department

approved

attendance,

your

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P.S.

licisure,

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license

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ndt

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113 a 1WSV2OIO -

Checklist Name Instructions Ii

: - Providea recentCriminal tlistory RecordsCheck (CHRC) frothS the statepolice or other state agency that Is the official

. . repository for criminal history record information for every

• statein which you have lived; worked, or completed professiànal. ±aifling/sthdies’forthe past ten (10) yen The report(s) mustbe . laid within 90 days of the date the applicationis submitted. For ipplicants living,working; or completingtrainlng/studiâ in ?ennsylvania, your CHRC rcqñestwill beaptomatically 5ubmittedto the Pennsylvania State Police upon spbmission of

. this application.The PATCHfee will be included at checkout; . YpurPA CHRCwill be sóht directly to theBoard/Commssioh. Youwill be notified if ad4itiotal action is required. For ndividua1s working, or completingfraining/stuthes outside Cr1 ml Thsto livin ‘ of Pennsylvania during the past ten (10) yeats, in lieu of obtaining Check . individualstate backgroundchecks, iou ma elect to provide . BOTHa state CIWCfrom the slate in whichyou cun-eritlyreside, I . ANDyour FBi Identity History Summaz, Check, available at hpjs://www.thig&/services/cjisfidentity-bistory-sunnnaiy

. checks.

. Pleasenote For applicants currentlyliving,working, or completingtraining/studiesiñQalifomia, Arizona, or Ohig: flue

. to the laWsof these states, the Board is notan eligible iecipient of ,. fllRG’s otyou± C}WC MU not be issued to you for upload tothe. Board.Pleaie obtain yo* FederalBureau Ofhivesfigafion (FBfl

• [denthyHistory Sthiitnry Check availableat the link noted

• above. Provide an officialnodflcafión.of inforthation(Self Queiy) frOm

. theNational PracififonerData Bank. Pleaserefer to the NPDB websitefor additional infomiation. When you receive the• Databank Report “Responseto ydur Self Qdery,”you will nóódfo upload itto your . onlineapplication.The report will need to be uploaded, where . - rompted, in .orde to submit your application. : Contactthe BOC andrequestan official verificationof• examinationregistration letter to be submitteddirectly to the Fiam Eligi‘blUlu Bdar& This is Onlyrequired if you are applying fbr a temporary thIeffc trainer license.

ala E

10fl112019 rchecklst Name j Instruefious Contact the licensing authoritiesof the states, territories or cdunfrieswhere you hold or hate evcr held a license, cerfificite, ermit,-registrationor other authorizatiOnto prathoe a health relatedprofession (whether active, inactive, expired or cuirent) L 1 andrequest letters of good standmg/venficafionof licensure Standing (LOGS) in . thstStateorjurisdiction. The letter must include the foflowinE:

• [icenseissu and expirationdate, license status (current or expired)and disciplinazystanding.The letter(s) of good . danding must be sent directly to the Board. affonal Dontactthe SOC and request an offi ial verification of terdflcafion ,erffficaffohletter be sent directlyto the Board.

. DompleteecSion I of the Verificationof Graduation from an

. 4.proved Athletic Trainer Pmgram Form and forward to your Record of athletictrainer tducation prograth for completion of Section Graduation 2. The school must return the completed verification directly to the Board. The form will be available for download and rinUng when the application is subñlfted. - Pleaie uload a CurriculumVitae/Resume.us ing!fl periodsof

. employmentor unemployment (i.e., child rearing, research, etc.) from graduation from yotrhihestlevel ofeduc3tion to present Resnme/Curriculum (theeducation completedwhich qualifiesyou for this license). Vitae Thelist must be in chronologibalorder,including the name, city md state of the employer, dates of employmefitor advanced .: education/trainingfinclude the month and y3 and description of thepractice activity

3,3 1W31f2019 Evaluation results: Board/Commission: OsteopathicMedicine License Type; Athletic Trainer Obtained By; Application ii CheckList Name j[ — Instructions [f this application is not completedwithin sixmonths, updates of, certain scctions of the application and upporfing documents will be required. If applicable,background check documents cannot be • Dlderthan 90 days from the date of issuance. JIthis application is Application hot completedwithin one yeaz you will be required to completea new application and resubmit the application fee. Youmay not Jcracticein the Commonwealthof Pennsylvania unUlyou have been issued a license, certificate,registration,permit, or authoñzation. Applicaton Fee [Anapplication fee of2QO‘“A is required. Please note that all fees are non-refimdable. iocO. 00 All healthrelated licensees/certificateholders alid fUneral directors are considered “mandatoryreporters” under section 6311

of the Child Protecth’eServices Law (23 P.S. §.631]). Therefore, all persons applying for issuance of an initial licenseor certificate from any of the health-relatedboards (except the State Board of VeterinaryMedicine) or from the State Board of Funeral Directors are req4lfredto complete,as a condition of licensure,3 hours of approved training by the Department of Human Services (DHS) Child AbUSC CE on the topic of child abuse recognition and reporting.After you have completed the required course, the approvedprovider will electronically submit your name, date of attendance, etc. to the Bureau.For that reas6n, it is imperativethat you register for the course using the informaflohprovided on your applicationfor licensurelcertification.A list of DHS-approved child abuse educationproviders cartbe found on the Departmentof State Website.

•

LaX

1073112019

Dat Cli

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. Name . .

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athletic

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For

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only

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your

you

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background

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criminal

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and

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states,

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CHRC

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request

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from

report

additional

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letter

past

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the

state

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past

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not

your

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agency

you

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of 2l3 r

1W3112019

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g noGsI

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of education/training

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list education

request

state

graduation

practice

Board.

ujiload

school

must

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issue

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the

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letters

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disciplinary

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education

employer,

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and

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sent

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request

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other

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directly

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highest

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date,

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month

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completed

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held

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city

of in Va PERFUSIOMST ioniaoio Evaluation results: Board/Commission: OsteopathicMedicine License flpe: OsteopathicPerfiisionistk1xfl?cX11 Obtained By: Application + IeqaØI’f

_CheckList Name_IL Instructions If this applicationis not completedwithin six months, updatesof certain sectionsof the applicationand supportinjdocuwents will e required.If applicable, backgroundcheck docnmenti cannotbe older than 90 days from the date of issuance. If this application is Appilcallon aot.completedvithin oneyear,ou will be required to completea new applicationand resubmit the applicafiot fee.You may not ,racfice in the Commonwealthof Pennsylvaniauntil you have seen issued a libensc, ceiIifice; registration, permit, or authoñzáffon An applicationfeebf$stis requitedfor Osteopathic Temporary Graduate Pérfiisionit.license and MI OsteopathicPeitsionist Application Fee license.An application fee of$481sreqbfredfor the OEteopathic rrary Provisional PerThsionistlicense. Pltase note that all C,letefeesare non-refundable. $20.00 Section 1of the Verificationto Act as a Supervisàr for Cérfificalion of a TemporaryGraduatePethsionist Form andf nvard fo your Supervisor supepiisorfor completionof Section2. Thisis bnlyrequiredif yoüareapplyiñg foraTemporaryGraduatePerfimibnistliceñse Allhealth-ielatedlic&nseés/certificatdholdersandfuneral ofiheçtors are:ëonsidered “mandatozyreporters”Undersection6311 the Child Protective ServicesLaw (23RS. §6311). Therefore, : allpersonsapplyingfor issuanceof an initiallicenseor certificate froth any f the health-rel4ted.boards(exceptthe State Board of VeterinaryMedicine) or from the State Both of Funeral Director

• re required to complete, as a cbnditionof licçnsnre,3 hours of CE approvedtrainingby the Depàrtmcntof HumanS&r’ices(DHS) onthe topicof childabuse recogmttotiandreportmg.After you lectpnicallybive completedthe required course,the approvedprovider will submit your name, date of attendance,etc. to the Bureau.For that reathn, ills imperativethat you•registerfor the • courseusing the information provided on.yourapplicàtionfor licensure/certification.A list of DHSapproved child abuse education .pmviderscan be found on TheDepartmentof Slate Website:

In 1013112019 j__CheckListNamç_jj Instructions Providea recent CriminalHistoryRecordsCheck (CNRC) from

• the statepolice or other state agency that is the official repository for criminalhistory record information for every

• stateinwhich you have lived,worked, or completed professional , Lrathing/studies.forthe past five (5)years. The report(s) must be datedwithin 90 days of the datethe application is submitted.For applicants.living,working; or completingtráining/studieà in Pennsylvania,your O{RC requestwill be automatically submittedto the Pennsylvania StatePoliceupon submission of thisapplicaddi. The PATCHfee will be included at checkout YourPACHRC will W sent directlyto theBoarWCothmissioñ. Youwill be notified if additionalactionis required. For triminal HISOl7 ilIdMdUaIS living, working, or completingtraining/studies ouftide Check ofPennsyWaniadufing the past five (5)years,in lieu of obtsfn!ng individualstate backgroundchecks, ou may elect to provide 20111 a state CNRC from the statein which you currently reside, AflD yourPSIldenfit History SummaryCheck available at

. https://www.thigov/sintices/cjistidey-history-sumsnarj.. checks. Please note: For appliàants currentlyliving,working,or completingUainiñglatudiesrn California,Arizona, or Ohio: Due to the laws ofthese states, the Board is not an eligible tecipiènt of cmcs or your CFWCwill nat be issuedto you for upload to the Board.Please obtain ydur FederalBureauof [denfity Investigation (FBI) History SiimrnaiyCheck;vailab1e at the link noted

ibdve. - Providea official notificationof information(Sell Query)from theNationalPracitiober Data Bank Pleaserefer to the NPDB for Databank Report wébsite additional information.Whenyou receive the “Responseto your Self Query,”you will needto uploadItt your onlineapplication. The report will ffeedtobe uploaded, where pfompted,in order to submityour applicàffon.

ComplefeSection 1 of the VerificationofPerThsionistEducafion Education, jn andforward to your schbolfor completionof Section2.The Verification.______programmust return the óompletedverificationdirectly to the

2)3 1013112019 Checklist Name]. Instructions f ConthcttheABCP or otherNationally-recognizedcethhig agencyandrequestan officialverificationthat you are eligible . . have Exam Ehgibthty.. and appliedto sit forthe certificationexaminationto be sent direotlyto theBoard;This is onlyrequired if youare applyingfor

, a TemporaryGraduate Pethisionist or Temporaryprovisional perfhsionistlicense: Contactthe licensingauthoritiesof the states,territoriesor countrieswhereyouholdor haveever helda license,ceffificate, permit,registrationor otherauthorizationto practicea health- relatedprofession(whetheractive,inactive,expired or current) Standin ‘‘ ocs’ and requestletters of goodstanding/verificationof licensure m g ‘ that state orjurisdiction. The lettermustincludethe following: [icenseissue and expiration date,license status (current or expired)mid disciplinary standing.The letter(s) of good

. standing must be sent directly to the Board. Youwillneed to upload, where prompted,proofofprofessional liability insurance coveragethough self-insurance,personally urchased insurance or insuianceprovidedby your emplo’erfor Malpractice theminimumamount of$ 1,000,000.00per occurrenceor cJaims Insurance niade. This proof of insurance/certificate must include your

• name and indicate that you are covered under this policy while performing perfusion servicesin theCommonwealth of Pennsylvania. . Contact the American Board of CardiovascularPerfusion (ABC?) Certification or otherNationally-recognizedcertilSringagenày and anañge for your“credentialverification” to be sent directly to the Board.

. Pleaseujiloada CurriculumVitae/Resumelisting!li periodsof . employmentor unemployment(i.e.,childrearing,reseatch, etc.) fromgraduationfrom your highest levelofeducationto present Resume/Curriculum (the educationcompletedwhichqualifiesyouforthis license). Vitae The list must be in chronologicalorder,includingthe name, city and state of the employer,dates of employmentor advanced education/training,(inäludethe monthandy.ç)3 ai4 description of thepractice acfivfty.

3,3 Child

iwalmclo

Supervisor

Cerfificafion

Application BoarWCowrnission;

Obtained

License

Evaluation Applicafion

‘

CheckList

Abuse

Type:

By:

results:

Fee

Name

Application Osteopathic

Website:

coiase

electronically

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approved

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frtjj

all

directors

you

supervisor

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license.

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authorization

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racfice

certain [ftlils

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een

the

persons

required

health-related

required.

application

are

completed

application

issued

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topic

using

that

application

For

applying

sections

non-refimdable.

are

training

providers

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Section

Medicine)

for

applying

the

Provisional

that

the

application

Protective

thç

Medichi&

èoiidered

Graduate

submit

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chiN

completion

days

complete,

Commonwealth

within

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the

applicable,

fee

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for

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from

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the

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list

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the

recognition

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of$40

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imperative

course,

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required

date

Section

condition

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boards

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you

date

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application

full

Peunsyltania

ZA\

eaa4

ahd

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the

license. within

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(except

for

holders

and

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initial

to.Aeias

supporting

that

check

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approved

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attendance,

your

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and

licensure,

reporting.

six

you

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required

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the

license

forward

for

ajplicaflon documents

fee.

and If

permit,

child

months,

only

under

6311).

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this

until

State

provider the

You

fimeraj

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documents

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note

etc.

of required

abuse

application

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Temporary.

hours

Therefoie,

Board

State

may

certificate

updates

complete

for

that

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license

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your

for

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üot

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6311

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113 a 40131)20W CheckList Name - Instructions Provide iF a recentddmink HistoryRedordsCheck(CIWCD)from thestatepoliceor otherstateagencythat is the official . repository for criminal history record Information for every statein whichyouhavelived,worked,or completedprofessional Lraining/studies.forthepast five(5)years. Thereport(s)mustbe . datedthin 90 daysof the datethe applicationis submitted.For .. applicantsliving,worldns or completingtaming/studies in Pennsylvania,yourCHRCrequestwill be automatically submittedto the PennsylvaniaStatePolice upon submissionOf thisapplicafid. ThePATCHfee willbe includddit checkout

• YourPACHRCwiUbe sentdfrectlyto the Board/Conimission. Youwill be notifiedif additionl actionis required.For ‘mlnal idividuis living,working,or completingtraining/studiesoutside Check of Pennsylvaniaduringthepastfive (5) years rn lieuof obtaining . individualstatebackgroundchecks,you mayelectto provide ROTHa state.CFmCfromthe state.inwhichyou currentlyreside, • ANDyow FI IdentityIflstbrySummaryCheck,availableat theckhps://www.fbigovJsenrices/qis/identLty-histoiy-summary

. Pleasenote:Forapplicantscuirenifyliving,working,or completingfraining/tudiesin California,Arizona5or Ohio:Due to the laws ofthese states,theBoard is not aneligibletecipknt of CImC’s OryourCIWCwillnbt be issuedtoyou fbruploadto the . Board.PleaseobtainyourFederalBureauofInvestigation(FBI) [denthyHistorySiimmaiyCheck,4vaiiableatthe linknoted ‘ above. .. Providean officialnoli&adon of infoimafion(SelfQueiy)from

• he NationalPractidoherDataBank.Plçasezvi totheNPDB Databaak Report wébsitefor additionalthibimafion.Whenyoureceivethe ‘1Responsèto 31ourSelfQuery1”you will needto uploadit to your Dulineapplication.Thereportwill needto be uploaded,where prompted,in orderto submityour application. DomplefeSection1 of theVerificationof PethisionistEducatiob Education ft,rmand forwardto yourscitholfor completionof Section2.The. Verification roam mustreturnthe completedverificationdirectlyto the . ,oard.

2i2 10/31/2019 CheckList Name Instructions Conthct the ABCP OrothèrNaUonafly-recognized,cerfffyli]g

. agency and request an officialverification that you are eligible

. . - ‘ and have Exam Eligibility.. a,lied to sit forthe certification examination to be sent directly to the Boart This is only required if you dre’applying fot . 3Tempora]y GraduatePéthisionist or Temporarjprovisional . pethiónist license.

. Contaotthe licensing authóHffesof the states, territories or

•countries where you hold or have•everheld a license, certificate,

• permit, registration or other authorization to practice a health relatedprofession (whether active, inactive, Lette ° f G d expired or current) and request letters ofgoadstanding/verificationof licensure in . n mg ‘ that state orjurisdiction. The letter must include the following: . Licenseissue Andexpirationdate, license status (current or . expired) and disciplinarystanding. The letter(s) of good . - itandlng must be sent dirçctly to the Board.

. Youwill need to upload, where prompted, proof dfpmfessional - liabililyinsurance coveragethrough seW-insurance,personally. purchased insurance or h!suranceprovided by your emplo’er for Malpractice . the minimum amountof $1,000,000.00per occUrrenceor claims Insurance made. This proof of $nsurancwcertiflcate must include your

. , name and indicate that you are covcied !nder this poliéy while peiiorming perfusion services in the Commonwealth of

Pennsylvania. . . Contact the AmericanBoard N of CardiovascularPerfusion (ABCP) or other N.tionally-recognized certifring agency and CrifficaionC arrange for your “credentialverification” to be,sent directly to the Board. Pleaseupload a CurriculumVitae/Resumelistingpjj periods of . employment or unemployment(i.e., child rearing,reáearch eta) . - from graduation from your highest level of educationto present Resume/Curriculum (the education completedwhich qualifies you for ‘thislicense). Vitae The list must be in cbronologicàlorder, includináthe name; city and state of the employer,dates of employmentor advanced . * . ‘Aucadon/frahiing(includethe month and y3 and description

. . f the practice activity.

313 IO!311201B 3uIy i gtoa’j Evaluation results: BoardlCommission: OsteopathicMêdiçine License Type: OsteopathicPerilisionist -j. tenpofo’j Got\& fls-1Asrcntsf Chained By: Application ftaSsrars\ tRr-SA

CheckList Name j. Jastructions If this applicationis not completed within six months, updates of •. certain sections of the application and supporting décuments will berequired. If applicable, background check documents cannot be older than 90 days from the date of issuahqe.If this application is Application not completedwithin one year, you will be re4uired to complete a new ajpiication and resubmit the applicationfee. You may not

. practicein the Commonwealthof Pennsylvania until ypü have been issued a license, certificate,registration, permit, or

. authorization An applicationfee of$fliEre4ufred for Osteopathic Temporary

. Graduate PerThsionistlicense and lUllOsteopathic?erfiisionist kpplicatIon Fee license. An applicationfee of $4 is required for the Osteopathic

• TemporaryProvisional Pethsionistlicense. Please note that all fee are nön-refimdable. 95. (30 Complete Section 1 of the Verificationto Act as a Supervisor for Certification of a TemporaryGraduate PerThsiofflstForm and forward to your Supervisor supervisorfor completion of Section 2. This is only required if you are applying for a Temporary GrnduatePerffisionist,license All health-relatedlicensees/certificateholdets and funeral dfreqtarsarc don’sidered“mañdatoiy reporters”under section 6311 of the Child Protective Services Law (23P.S. §6311).Therefo±,

• all persons applyingfor issuance,of an initial license or certificate om any of the health-relatedboards (exceptthe State Board of VeterinaryMedicine) or from the State Boardof Funeral Directors are required to complete,as a condition of licensurc, 3 hoUrsof’ approved.ftainingby the Deparuncnt of Human Services (DHS) Cliii Abu on the topic of child abuse recognthon and reporting.After you iaW completed the.required course, the approvedprovider will . electronically submit your name, date of attendance,etc. to the Bureau. For that reaon, it is imperativethat you register for the coute using thç infomiafiobprovided on your applicationfor licenspre/derflficafion.A list of DHS-approvedchild abuse educationproviders can be found on the Departmentof State Website:

in I tasaiaal9 Education D Verification Check triminalnlstorv r a t CheckList a bank R epo Name • form Complete online “Responsó Provide Identity the CHRC’s website above. ,rogram prompted, to completing Please checks. AND Board. IL BOTh indiyidual of individuals jflps:f/www.fbi Your applicants.living, dated oard. ‘ou this ftainingfstudies.for state the Provide repository Pennsylvania, the Pennsylvania National state application. will and PA in your laws application. thin note: Please a for an History. which must Or thrward a stateCHRC be CHRC jiolice Section in to 19 recent state official FW of your additional training/studies living, for notified PractitioherData For order your the 90 return these obtain your you ;govfseMw4is/identfty-hstory-s Identity crinilnal backgroun4 or Summary CHRC applicants days will during The Pennsylvania Criminal to 1 working; The Self to notification working, other have states, of the yourschöol CIC the if ydur be submit PATCH fitah of hdbnnatka the additional report Query,” past the will Histbxy completed sent the lived, stató history Federal Veri&ation the Check, Histoty. the cutenily Instructions request past in or. date nat five checks, or your directly fee will agency Bank. Board Califçrnia, completing of worked, state State completing you five be Summary for the (5) will action infomaffon record applic$ion. zecd available Bureau When Records verification issued will will completion in years. ybu Police Please application (5) is living, to that be of which nçt to the or be is years; need may indludèd Perftsionist information you Afizona be to of trAining/studies required. completed is Check, automatically The training/studies an Board/Commission. refer upon at working, Check you Investigation uploaded, the you to receive elect eligible (Self the In directly report(s) f upload is to official for submission lieu currently link at available Section submitted. or (CIC) to the Query) For checkout upload professional Education or provide Ohio: the of ±ecipint noted NPDB for where to it obtaining must to the (FBI) 2.The in every &m outside reside, Due at to your from of For be the of a II

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3)3 I) PERFUSIONIST REACT WATJON STATEBOARb OF OSTEOPATHIC MEDICINE REACTIVATIONor STATUSCHANGEAPPLICATION‘,- AWED HEALIH PROFESSIONALS ‘‘ - -. First FuD g4j: News .

STATE BOARD OF Addmie . - .

OSTEOPATHICMEDICINE . , . . P.0; BOX 2649 Mdren :.

HARRISBURG,PA17105-2649 . •.. . , ‘Pfld.doLpa.qOViO5t- Aidran

or .

2801NORTHThIRDSTREET Email: - HARRISBURG, PA lljtO ., ‘r , UcenuNa , TehaphoneNo. For a news dw,o, Indala new mm& bejuw and abad, en B )I xli photoa,py of a Isgal dwnwn1 vflnp the flora diang. (i’ rnantego, cei1fflca, diveitd doog, legMdóaament b,dlceUn5rflklng ofa maiden name1 etc.).

HNama;. . -.

LICENSES EXPIRE EVERYEVENNUMBEREDYEAR REGARDLESS OF REINSTATEMENTDATE

REQUESTINGINACTIVESTATUS

13 CURRENTLYACTIVESTATUSREQUESTINGINACTIVESTATUS

I do notwIshto practicemy prvfessbn inthe Commonwealthof Pennsyivsnls and with to plaa mycense on an InactIvestatnL I uitersWid that to react! vats my kcannj w$ need to meet Thecor*nulna educedcn reoulmmenw.obtaIn IOnI JIWNII [nsjnfloe arid meet pv re.intNcmStskfIe nsesstnertas reifr94 bv.the Böárd. • Completegea 1 2nd 3 of(hoeppUcation. • REtmywr “AOUVUwallend walletlicenses, • Nofeebrequlmd APPLICANTSMUSTCOMPLETETHE FOLLOWING. —-______money Encle a chack or order. In the appropriate anioutti Usled below, made payable Io.tlw ‘Ccmmoii’oafth of • Penneylvanta., Ifyouhave been pmcffdngIn Pennsylvania beyond the eçlmtion data, Includes latefee of $5 per month or part ofa month. •

FEES ARENOT dr’ REJWNOIaE. money 01*1 pat be In US tmids7 Na: A pmcea&ngfee of $20.00wIllbe chaiged foreny dwdcormoney order rtrflød unpaidb?your baNGrsgtfllless of the mason r non-payment Youicenceiled check IsyouYretelptof payment 1. Anueunct $25. MNaticTmlner $37 —.7 -. S Geneft; Counselor !%./Fee.hicFudee $75 renewalfee + $50 reactivationFee. I PãtalàribV - ‘sjW ‘%e IncludesVi’enewal fae reactivationbe. a Ph3slclanAasIstont $10 . a ResplrabyTheaplst $25 $75 2. Coriçlete the legal quOtonnaim. ‘ . ‘ - .

II documenis wll be submittedto the Boardunder a name dWorardfrom your present name,submita copy of the legal • documentevidwicbwthe name change(te.maMage license,divorcedean, eta):

,4. ComplðeVefl onof P INoncllcaJmt -

Mt&i a durrent CtmfcuhimVitae Us*tç fl peiloth of employment or Unemplaymerd(i.e.. difld rbwfng reáathli etc,)frcm Vieeçlmtlw’ d$e of the license to present The eat must be to dimnoiodca! older. lndtte tie monthend -er, and Indicatetha atat&nt.!gln with Uiaerni,Iovrieqflocred.

I to

controged

is EffactIve Monitoring If

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10.

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prescdbed 6.

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ALL Indicate Insinnce $1,000,000.00

continuing FOR Board’s nnd FOR ethicaon

FOR must thomrMrdstotheBoardofflça. All fist conUnuTn

repast Provide NPDS

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substance(s),

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Acui,uncturtts hftp-JM.leals.stata.pauEfcMosftenisfl.ifuconsChactcfm7bdTtma=HU44w2014&seseInd=0&smthLwinthQ&aci= available education

The addiction OrAoid Section

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PHYSICiAN HEALTh.RELATED GENEUO

ATJILETIC

1,2017, Board-approved

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PFRFUSTION1STS. -

six

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For

a {09f2017) LEGALQUESTIONS. .7

ThE FOLLOWINGLICENSEREACTIVAVQN.QUESTIONSMUSTUE.ANSWERED.Ifyou answer•VES’to #2 thmugh*12, provide compretedetailson a separate sheet as wellas copiesat relevantdocument. Sign end date beJow...... - Yes Eyoü holdor have youever held a Ilcede. ccdlftcate,pomilt.ragi6nVâi or c*,oreuthodmffon to pmctlco anyhealththlatedpvfessron In enylete ajiidsdlcffon? Ifyou answered ye.; previde lbs prafsselon and . elate Orjufladlcaom .

-,uSfl . .. . -

. Have you wlthdmwnen application ftr a prfleslonal or occupational license, cerUffoate,Permit or • 2. registration,had an application denied or refused, or for discIplinaryreasons agreed not to app’ or mapply fora professionalor occupational license,certificate.permitorreglefrallon Inany stAteor jUrfsdldion? Have you had disciplinaryaction taken aflelnst a proièaeionai or ocupatoneF license, certificate, pen-nh. 3. ftglsfratlon or other authorization to practice a profession, or occupadah Tssirndto you In any ath or Jurisdiction a- have you agreed to voluntary surrender lleuof discipline? Do you currentlyhen any dlscipilnarycharges pending agàlrtht yew pmfasslonal or eroupaffonatficensa. ‘ certificate,permitCrregistrationInany slate orjudsdlctlon7

Haveyou been canvicted (found guflt pled gully or — nob conlandare), received prdbauoi withoul - veMictor eccelered rehebWlâtivedbposlliah (AnD), a to any -imlnaI charges, feIon9or misdemeanor, • hwludlng.anydni lawvlofétlorm? Note:Youera not requiredto disdose any ARDor other diminal matter thai has been ocpungadby orderofa court .

6. Doyoucurrentlyhave any criqilnalcharges pendingepd unresolved Inany state orjurlsdlctlàn?

Heveycu ever bud pctlcp- privilegesdenIed,revoked, suspended, or restricted by a hospital or;ny health • care faculty? ..

S. Haveyou.had yourCM registrationdenied, revokedor mticted? . Haveyou had providerprivileges denied, revoked,suspended or restricted by a MedicalAssistance agency, . Medicara,thUdpadypayorornnothareut6or Have you been charted b e’ hospital, uñWomfty,of resaimb facilitywith violathigresearch protocole, • fablflflngrasaarcli, or engaging in otherresearch mbccnduØ? Have you engegAdin the Intemperate or hebifualuse or abLa.aof elcobbi br-nsrtols, hOllucinogenicsor • dthardwgaorsubstancesthatmaylmpeirJudgmentorcoordlnallon7 . ,- SJbcaMay19, 2002,have you been the subject Ma civilmalpractice lawsuit? if yes, pleace eubmft a copy of theentlre CMI CompletEd,width must inãlude th. filIng dab and the dab you warnserved. Submit 12. alalament which includes complete details of the complaints that bavq been filed against you. “If you prevlousbvreperted the cernp’lalnt(s)to the Board provide liii docket number(s);

VERINCATIONOF INFORMATION - —

Iverifythat thisapplicationIs inthe originalftñnat es’suplled-bythe Depiit ant of Stale anti lisa notbeen alteredCrotherwisemodifiedLiamj way. lam swamofthe cladnalpenaltiesfattathperingwtpubne recordeorlnlomiationundo:19Pa CS. § 4911. Iverify-thatthe statement In thisèppkatlon are frueendcaaa to the bat ofmykiordedge,kitonnellonand belief. Iunderstandthatfalsestatementsare madesulgict to the penaltiesof 19Pa C.S.§4904(mIstingto unewamfaisl*uVi teumames) and mayrasukln the eüepenslop,revocatlon,-ardehiwof my license, cortificata,permitor reglenhion. Fret MIdS —______Full Name . .

Spclalsecudty# . Dab bi Birth’

Name of — ...... Unlvemltyor . Ywofor.dretlon School .

. . . SIgnature .. ,. . Vile Øtendew -‘

3 (09,2017)

- I. t9.f

VERIFICATIONOFPRACTICEI NON-PRACTICE

‘Your reacilvaflon cannot ha prccessad union this page 19completed“

Hays you engaged In or practiced In your protassbn In Pennsyrvarda since your license or cethñcailon 1. lapsedor since you placed Don Inactivestaluc?

Have you bean employed by the federal govamryeriL In the practice of your prcfacaion silica your a Pannsytvonlaflcense orcerilfication lapsed or since youplaced it on Inactivestatus?

IveiflythetthiseppfcetlanIs InTheodInsI formatas suçpCadby tha Dvpaxtnant of Stain and has môtbean alteredor etheMise modifiedIn anyway. I aft awn cf-the ednitnal penalties for tampefing with publIcrwrda or Infinatlon under iS Pa. C.S. § 6511. I vertt that the tementa In Vita epptca&n era (runand rarTud lathe beat amy knowteda,WarmsVon and balM, I undurtand Piatiblee statementsare made suNeetto the ponalUn of16 Pa CS. § 4s04 (relating Launawam faiab’icauonto autorwes) endmayresult Inthe euspenslcn, revocaffon,or denial ol my license, certificate, pennNottsfliauuon, -

SlgnattnnpTUnSOe Dale

4 Ii_QQQ (0912017) -. * r 7uv STATE BOARDOF OSTEOPATHICMEDICINE REACTIVATIONor STA US CHANGEAPPLICATION—ALLIEDHEALThPROFESSIONALS Flit Spd to: FullName

STATE BOARDOF • Aa . . OSTEOPATHICMEDICINE P.O. sox 2640 HARRISBURG,PA17195,2649 www.dos.ia.qOvIäat :: •or 2801 NORTHThIRD SWEET [morn - —- HARRISBURG,PA 17110 1LJc.nseNe.

-. - - - -

Fore name now dange, buIa namebalaw a’ th en a 3 Eli photccopy ala h,gai daa,mont vad4* Via namethange CL...iranlage rtfcate.dWcice4euga, legaldocumentTndMath,grotaWnaala maidenname, ala). ‘

NewNams: . . . .

LICENSES EXPIRE-EVERYEVENNUMBEREDYEARREGARDLESSOF REINSTATEMENTDATE

REQUESTiNGINACTIVESTATUS:

El CURRENTLYAC1WESlAms REQUESTiNGINACTIVESTATUS I do notwishto practicemy pruresslon Inthe CommonwealthofPennsylvaniaand wish to place mu license onin inacilvestatus. LLdirInd that to reathnte n Dowse. Iwillneed to meet the cottAnn educeffon rMuIraments,obtainnmfessiI liability lrrgfla. and raë& anyrw-e&g. dffiIi aMPsesassnisifis inuIrèd by the Boed. • Compietopegee I and 3.of the apIlceton, • Rélam your’Acite’uU end wallet licensee, • Nofee is required

APPLICANTSMUSTCOMPLETEThE FOLLOMNG

‘ Enclose a check or money order, In the BppTDpIIQtC amount listed below, made payable to the ‘Commonwealthof Pannsytvargs. - Vyouhave been practlc’ngIn Pannaylvania beyondthe e4cpiraffondate Includea-lab fee of $5 per month. orpadofa month. -

FEE ARENOt REFUNDABLE.Check or money OMIT must b in “US runds 7±: Aprocessing fee offlO.QOvMlbe charpodforany c4ieckOrmoneyorder returnedunpaidby yourbank, regwss of the reason fornonpaymenl. Vourcancaflod chackbyourrecelptofpsyment

a Acupunctrtst S5 . a AtNeticTrainer $27 - . * a GeneticCounselor $12 “Fee Inciudea$75 renewalfee + $50 reaaflvallonMe. Perfuslonist. - - Fee Includes reniwal tee + 57 reaàdvaffon tee. a Physician Assistant $10 a RespiratoryTherapist $25 . “U

2. CimpIewThe1e1queaUonnpira .

ciJnents eW be submitted to tñe Bnesdunder &normadMerer.t1mm If >tur present nanis, cihnft a copy of the legal • docunfl evi&ncing the name change (he..menlafle flcenn, dJvuce decree, ala). . -

4. - Coniplatethe Wrificaffonof Practical Non-Practiceform. Aach a c°arad CurrW4umVPae listingfl peilods ofamplo)meM& tmemp4 ymant(Lt-thd rearing,research, it) from thi açdration dMa of the Kosneeto present 11w bt must be In duono1o1csI C$It, fr’e the month and enr, end

the hiwtiidi - !° sbialbntiv the entlOvmoN cred. ... . 1 (O9O17)

officialnotiifcation of lnknpation (Self Query) from the NationalPractitionerData Bank. Please refer to the 6. NPDBwebslia for additionalkiithmation.When you recelge the ‘Response to your SelF Query” rwwaid the entire report dlmc1lyft the Board Office. YwehouW make a coovfotyour records.

- - —-t’ : -_._-_,.._. .. . — k,’— h.—2tv’ — — — ..t — fl

Contlnuinttaucatlpn I ....‘‘C.. ,..r ALLHEALTH-RELATEDLlCENSEES Act31 of 2014 requIres that ilcenseesmptete at least 2 hours of Board-approved continuinoeducation In chlkiabuse recognitionand reporting requirements. Detailscan be Wund at w.dos,oa.pov Fore Ustof Board-approvedproviders,choose the ‘Act31 Mandated ChildAbuse ReporterTmlnthg’link. Verificationolcomplellon mustbe sent elecfronicali directlyfromthe course povlder. Please note that it maylake 7-10 dan for the rovlder to submit

to : .

FORATHLETICTRAINERSONLY In order to reactvath yourilcense and be in co!npilonce.Wtththe Board’s continuing • education reqLiiremants.you willneed to providea 9py of yctir currenlBOC certlfiffon.

FOBnENrrIC CoUNSELORS.)ERFUSTIONISTh. & RESPIRATORY7HERAPiSTS in Orderto reactivate yourilcanse 9’ and bela óoniflncewtLhtheBbard’s àónflnpthb edUcation rqufr&nenb, you willThesdto provide proof of meclln the Board’scontlrndng education rnquimmen!s. Continuingeducation roqiiremenffi can be found at ww.dos.oagov1ost,

FORPHYlCLM4ASSISTANTSONLY; In orderto kacuvate your license and be Incoinpffsncowith the Board’s conlinulngeducation requfrements, youwillneed to provides copy of your cwmnl NCqPA cedificatlon. Ociold Continuinu Educatkst Section 9.1(e)(2) of ABC-MAP thquIres that all ptesathem or dispensers, as defined in Section 3 of ABC-MAP,complete el least two houri of conllnLiingeducatbi In—management, the IdentIficationof addictionor inthe procilcesofpreswibingor dbpens’mgof oploidsas a porffonofthe total thntinulng educationrequired. IC. The required continulnp education is part of Thetotal required and must be token from a Boad-appmved cootinumg educatia provider.

91w AchievIngBetterCare by Monitoringflit PrestpUons ProflmmMt (ABC-MAP)(Act191 ofZObI,as amended) is available on the Legislature’swebsiiaat .

.1i ...... fl. ‘tP-1i( 4tqt3.9r c2• 7 4i* W.fZ’’.’ 2WPt fl) I 3’9. t ‘t.,qIri.

• . ALLAcupuncturists a GeneUcCounselon: Shall provide proofof pnfessiohsl itabliltyInsurance coverage through self: ii. Insumn* p.arsonWrypurchased lasurerice or Insurance provided by your employer for the minimum amount of $1,00D,000.COpar occurrence or blebns made. This proof of lnsurancWcediflcate must Include your name and Indicate that you am cbvered under this polity while peglcnnlng cervices goilemed by your license in the Commonwealth of Pennsylvania.

Ifthis applicationis not completedwithin clx months, updates ci certain sections anWorsupportng documentswillbe required.

EffectiveJan. 1,2017, act 191 of 2014.requims oilprescribers end dispensers lo registerfor the Pennsylvania Présrsiptlon Drug MonitoringProgram (PA POMP).Prescdbers are required toquery the PA POMPSystemforeach ppffentthe Qet limethe patient Is prescribeda controlledsubstance bythe prescriber,when there is chnicnicancem that the patientmay be abusing or divertinga controlledsubstance(s), and/oreach time the peEler is prescribed an oplolddrugproducia a bãn*adiszeplne,Tojeam more end to register,please visitww.doh:pe.oov!pdmp. -

2 ______- ______

(0912017) —______LEGAL QUESTIONS

THEFOLLOWINGLICENSEREACTIVATiONQUESTIONSMUST,BEANSWERED.Ifyou anwar ‘YES’to #2 through #12 provide complete details on a separate sheet as wellas copiesof ralavantdocumehis. Sign and date below, - .. Yes No Doyou holdor have you over.helda flcense, certificate,penaft,raglsbaUonor other authadnuon to practice anyhealth-related professionInanystale orJurtsdlction? if you answered yes, provide the profàssloii and stale orjurtsdlction,

UST: - Have you withdrawnan application for a pvfessloneI or occupational license. certificate, permit or 2. registratIon,had an eppllcaUondenied or refused, or for disciplinaryreasons agreed not to apply or mapply, fora professional oroócupallonallicense, certificate, permitor registrationInany state orJuttadIdlon? Have you had dleclpinàiyaction taken against a professional or occupational llcbnse,.cedlficata, permit, 3 regiebation or other authorization to practice a profession or occupation Issued to you In any state or Jurisdiction’ or have you agreed ib voluntary urrender In lieu -. of discipline? • Do you currentlyhave any dlscilinary charges pending against your professIonal or occupational Jhznse, • certificate,permitorregistrationin any state orjudsdlction? Have you, been convicted (found guilty,pled guilty or pled nob’ contenders), received probation without verdict‘oraccelerated rehabilitativedisposition CARD),as to any criminalchergea, felony or misdemeanor, • ‘ lncludln any dmg lawvIolations? Note;You am not requiredto dIsclose any AR!) or other criminalmatter that has bean expungedbyordorof a court.

6. Doyou currentlyhaveany criminalcharges pending end-unresolvedInany state orjudsdIctlon?

Have you ever had Ørncice privilegesdenied, revoked, suspended, or rastrided by a hospitalor any health care facllit9?

B. Haveyou had yourDEAregistrationdenied, revoked or restricted? Haveyou had providerprivilegesdenied, mvcked, suspendeddr restricted by a MedicalAsslslance’oflanoy, —______‘ Madicare,thlrdpady payororancther authority? Have yoi4 been charged by a hospital, university, or research laclity with Wolatng researct protocols, falsifyingresearch, or engagingIn other research misconduct?

Have you engaged Inlbs intemperate or habitual use or abuse ci alcohol or narcotics, halluclnogsNcs or other’dnigsor substances that mayFmpalrjudgthentor coordination?

SkmcoMay 19, 2002, have you been the eubject die cMlmalpracticelawsuit? Ifyes, places eubmit a copy tithe entire CivilComp!alnt,‘whichmust Include the tHingdata and the dateyog view seiwd.-Submjf 12. a statement whtch Includes compiote details of the compffilnWthat have been filed against you. ftyou previously reported the complaInt(s) to the Doard provide the docket number(s):

VERIFICATIONOF INFORftfl4kTION

IverI’ that this applicationIsIntheoriginalfomiatas suppliedbythe DepartmentofSlats end has not beenalteredorotherwisemodjifodInany way.,l am awareof the almInd penaltiesfortamperingwithpublicreonrdsor Informationunder 10Pe, C2. §4911. Iveritythatthe slalementefri thisapplicationare Ins end corm to the best ofmyknowledge.Informationand belief. Iirdentand thatfake stabeients am me subjectlothe penalties of 18Pa 0.5. §4O4 (relatingto unawomfalelficallonto authorities)and,mayresultin thesuspension,revocation,ordentalof mylicense, certificate,permitor regi*atieo. FuliNami be! - First - Middle f

- Social Staidly # , Date of BIrth Name of Unlnnltyor YearofGmdisatian School

Signature ‘ - - Date — (Mandatoty) —______

3 epptcaton vile Signature

permit em

a veis,

aware

tat

Pennsylvania lapsed Have

Have

reslantlon.

Cs. of

of am

th Ucansas

ifie.rjimlnal

§ you flue you

orsince epplcailcn

4904 endzmd engaged

bean

(m4elln

license

you

penalties I&

employed In

placed

Your

In to

to the

VERIFIcAtION

thetcat

w.swam

certification adginat

f prc!tced reactlvallonCannotbe

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of ft)stflctbn fcotat

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the

eMedge,

lapsed

federal assuppllad

with

your

status?

pubIc

authorities)

pmfesdon

govonimoni

since

WarMflan

OF b3

rerards the

you

PRAC11CE

processed Departnent t,d

placed

in end

mayres*aH In

lnionnaUsn

Permaylvania

beret

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the

on of

practice pnless

I Smta

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I end

NON-PRACTICE since

cuepaTidon,

Hits 10 of has

thatf&ae Pa.

‘aurproIessIon.

your

page nfl

CS.

been

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là

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slimed

4911. completed’” Date

or pi

since

cerflilcadon

are

vaNfy othernlse donlal

Middle

made

that

your of

subject :‘ my modified the rca,va,

abtaments

tote

any ce,lIe,

(o9r2017)’ pniSss

ad),

this

I 4. liCENSES fl NawName: . nlffcata For 2801 www,desj,a.govlost HARRISBURG, HARRISBURG, P.O. OSTEOPATHIC STATE Send • a kistk*oë I Ida CURRENThY REACTIVATION . urlofnthn dacklayaigrsc&ptoTpanapL AltarS,. dimipedior none fridloats the Complete FEEs orpartof.amonth. dowmentevldanchc PonnsylvanIe. Enetse If Complete BOX • .: . . NORTH . to:. doa,msnlswfll not . eplraon BOARD thtste difle, ARENOT 2649 wish . ‘ .aidrnoetiire-erthvr fl gurient EXPIRE a the the tHIRD MNetlorrelñer ResØtratwy Gqnefic ADJpTctwist Pettuelt deee, Nofeabrequired Compila thpt Return or to eny hyslclEnAasbthnt etaflnlti,v checic ACTIVE PA PA MEDIcINE OF.. hdJra Vudflceliorrol gaI pr date clfl to-readivatO ôun(culurn IflJN0AflE. 11105-2649 rr 17110 dice be leg,Idowma1 your STREET Co4nehr >vu or questionnaire. of EVERYEVEN pew etthrnfltad STATUS the pages or Themplst ormoneyorártetmed money the my have APPLICANTS Acdye n,ma in STATUS name profession Iloanse . Vitae Which Pric&e 1 . been my -4e STATE end order, below REQUESTING thange thdifng wail to cflnitar Iiàensn. $5 Emeth nn Ucepie MdnDa- Uailngft the Flail $37 30111w prathldng In the-Board Check and / REQUENG end -- In present In ern&o4’ment Non-Pmdce CHANGE . Name $10 skit (I.e.. the to $25 wallet rflkMg BOARD NUMBERED ai4ath Fsa No. I •S-io ot wlil applicatIon. 1ierlods MUS Commonwealth manlage appmpdala maneerdar In iès9ssme . under INACTIVE Include. need licenses, an unpdd The Pennsylvania .cw ala . B eurmd: otemptotnent tori, APPLICATION maiden 16 . a . list - OF In COMPLETE.THE Indies -. Bcense, name xli byyow p meet Ø must .. .4 1,1-c STATUS OSTEOPATHIC amount I n YEAR . name omit pflotpy renewal of t?:zi ffiaartbv:theEothd, diffeiord the beyond be $75 divorce . bmil( Pennsylvania . ;fl be conVnu eW4. .-. in . lisled or renewal

r REGARDLESé chronological hi fee r111.du.s . of unemployment . the from dcctee,etj. 94 a + STAWS: below, . - legal eçlmfloirdate, E be . your AUED bade.’ jJucaUori and . FOLLOWING: jtelephaeeNa. reedkatn d,anoM . F ., MEDICINE &therincn . made present $50 wish . . aider, .. a (La, rac1lvdqn . in rfluhmente. -______HEALTh payable vottthg place include Or nánm.subrnll . ctitWreeflng,research.einjrrom include .. lea A -. pocesslng for REINStATEMENr .. my . . ha to non-payaing.- the be. a license lath name the . PROFESSIONALS . month Iein-omMiarorei a fee fe Cemmormeaftft thanqaps py on . - 01*5 end c!$20.3Q en oft. Yaw - veer, inactive per --. cancelled ,nm.isoe month legal - and will DATE status. Irobflltv of be ( LZ •

to Monitoring Effective controlled Is • If

ii.

this 9. .

prescribed

6. register, .. ,

appflcation

I J

• •

à1fIÔIj,

Commonwealth *a $1,000,000.00

insurance, indicate

continuing

FQR Boad’s end FOR education FOR the ALL fist must continuing

NPDS report Prvvlda

Jan.

substance(s),

Program

please

orBoard-approved

records

Acupuncturists ,i. available The

addiction education Oplold Section be

a The

PHYSICIAN

ATHLCTIC HEALTH-RELATED GENETIC

beseol

1,2017,

controlled

webalie dlrictiytolhe

conlinutng

that en

raquire4

AcNevingaafter

viatt

requirements,

comphance education

education personally

not

CoptinuIno

(PA

official

elecfronicalw

you

the

v.w.doh.oe,poyIndmp.

proider.

per

act of

corppetad

aMlor COUNstORS’PERFUWflONIsTS. for

PDMP).

. In

the

TRAINERS

substance

ABC-MAP,

ASSISTANTSONLY;

Board

continuing

191 ethscatbi

the Pannsyfranta. occurrence

ad&lonal are

notification

Legislature’s

requirements,

Board

practices wWi

purthased

providers,

of each

Education:

Cenàiic

child covered

you

office

Prescribars

2014

within

LICENSEES:-

Care

dfradW

11w

time

wIll

ONLY; requirements.

ëcmpleta

Office.

abuse education

friforrnation.

the

or requires-all Boards

Counsaloru:.Shsli need

choose

the

weblite

under

information

claims

insurance prescribing Monitoring prescriber,

you Iron,

Section

recognition

months.

patient ...

You

will

cohllhcing

The Is

providee

required

order

the In

this

Ant

at:.

made. should lent

need

pad

prascdbers

When ConUnulngeducaon order

courn

9.1(a)(2)

All

31 when Ad

updates (Self or

policy

prescribed to

of two

and

Pmsctlphons of diopeneing

ineuranca

reactfvatö to makes This

copy

you

the

education provide

progdet. 2014

Query) provide there reactivate

query

hours

reporting

Mandated

while

Mel

and receive

proof of RESPIRATORY

ABC-MAP

carffi!n raqulmä

copy

yo&

the

1mm

dispensers

proof

your dbilcai

required

of ‘

provided

copy

oplold

performing .

tequlremenls,

continuing Please

your

requJrements.. of

Program

forvour

opiotds

current

Chd

the

sections

the

license

requkuments

insurancefcerflflcate - PPM?

that

of .

powem

ticense

daub

prolossionol

requires

your

NillonI mote-IhatIt flnponae

Abuse

and

11CC by licensees

records.

THERAPISTS:

and System product

education

endor

cunant

mtnt services

your

end

portion (ABC-MA?)

that-the

certificatIon.

yoU

Reporter

that

Details

Pmctlioner

can

employer mettiake suppoiting In

to will

pompiele or

for liability

NCcPAverffficalion.

all

For

cube compliance

in a your

taken

patient

each

governed compflante

need

prescribers

ceo

the beruodiazepine,

Trathlnw’

found

pain

(Actigi

insurance

must

total

Pennsylvania Self ...

patient be

from

7-10

Data (a

For

may managomerd,

order dooument

found

provide

heal

continuing

Query,’

the ww.dos.Da.oovh,st. wIth

include

link. dn

Bank.

with

c12014,

the

Bdwd-approved

coverage

ebusing

your

minimum

dispensers,

the

mAcflate

first

for Vedflcaflon .

hours

the

proof

vMw,do&ra.gov

rllI

Prescription

fdiwwd

Boarde

Please -

your

the

education Board’s

time

learn

license

the

of or of

oiP

rmvidai

thmugfl amended)

roqufred.

the -

diverting amount identification name Board-approved. meeting

your

mow

refer

continuing 4hs

patient

continuing

completion required. defined

License

Drug

(00/2011)

and

calf- to

entin

ajid

Ike

là the

sijbmil

(lie

For

I __-

(09*2017)

LEGALQUESTIONS -

rmE POU OWINGLICENSEREACTNATJQNQUESTIONSMUSTBEANSWERED.Nyou answer ‘IPS to *2 through #IZ pmvlda complete detailsone separate sheet as wellas copies of relevantdocuments, Shin and dift beloW. VYiITh.

•Doyouhold or have you aver held a liceiia, certificate,permit,registrationor other authorizationto practice anyhealth-relatedprofessionfriany state orJur1sctlon? if you ensweted.ye., provide the profession and stale orjwkdicfian. tlST[ -. Have you withdrawnan application for a professional or occupa*onal license, certificate,- permit or 2. regIstration,had an applicationdenTedor refused, or for dlacpilnai reasons agreed not to apply or reapply bra professionaloroxupaflonal license, ceitificate,permit or rngb&afioninany ethIcorjurlsdlctJon? — Haveyou had disciplriaiy actlbn taken against a prosslonal or occupational license, cerflr,calo, perthil, 3. registration or other authorization to I practice a profession or ocnipatIoi issued to you In any state or Jj!hn or have you agreed lo voluntary surrender In lieu of discline? Do you currentlyhave any disciplinarycharges pending aueinst your proressionaror occupational licence, certificate,permitorregistrationin any state orjudsdlcflon? Have ybu been cvnvfded (found gUilty,pied guilty or pled nob contendem), recelvad probation withouiT verdictor accelerated rebablUtetivedispositionCARD),as to any criminalchargos,.relcriy or misdemeanor, Includingany dhsglawvtations? Note;Youem not,required to dlsclxe any ARt] orother c,Imfnatmetler that has been byorder of a cowl. wcpunaed 4 8 Doyouwrrenliy haveany cflmfriaicharges pendingand unresolvedinany state orjutisdlction?

Haveyou ewr bad practiceprIvilegesdenied, revoked, suspended, or restricted by a hospitalor enyhealth careffichuty? a. Haveycu had your0EP.registrationdenied, revokedorresirictad? Haveyou hod providerprivilegesdenied, revoked,suspended or restrictedby a MedicalAssistance agency, . Mam,thlrdpartypeyororanothereuttaily? Have youbeen drergid by a hospital, -university,or research facilityth viojating research protocols, falsifyingresearch, or engagingin other research misconduct?

Han you engaged In the Intamperata or habitual use or abuse of alcoholor nardotics, hailuclnogenlcsor. otherdrugs oraubslahcas that mey imp&rjudgmenlor coordlnslion? Since Mey19, 2002, haveyou bean the sUbjectofa clviimalpracticelawsuit? Wyas, plaaae submits copy of the entire clvii Cothpialnt,which must include the fIno-dste and the dab you were sewed. Submit iz a atatementwMch Includes complete details of the complaints that hva been filed againutyou. Ifyou pmviousiyreported the complaint(s) to the Bdard.provide the docket number(s);

VERIFICATIONOF INFORMATION-

I verifythat thisapplicationEsh the originalformal as applied by the Departnenlol State and has tht been altered or otherwse modtedIn any way I mmsem of thecriminelpenaltiesIcr tamjdng withpubic ,ecorrlsor Infenruilanundor 18 Pa. C.S.- 4911. 1verIt that the etatemeiIs In thisapplication bus and tothe básl ofmy I em mnd krwta4ga, informelionand belief. understandthat falsestflqnenls em made Peel tothe penaltiesbf 1BPs 0.8. §4904(retsfngto iinswvmfalstflca&nto authoiltias)and ma)Lre&utInthe siLpanslon,mvoca4ion,ordentalamy cortiflcala,pemifloraglsmtoa. lire,

FuliNama - 1.511 FWI Mida j Social Secwlty# . Data of Birth Nasa. of UMversltycr Year of Graduation School tUN Date (Mahdatoi

3 (CB/2017)

VERIFICATIONOF PRACTICEI NON-PRACTICE

— Your reeeftvaflan canflot be processed unless title page 18compMed ‘a’ mt VUIIName

!uQr No.

tc-. ‘ .j..

Have you engaged In or pmctlced In your mfesslon hi Pennsylvania since your Ilconso or corliflcallon 1. lapsed or since you piad Itoil Inactive status?

Have you been emp!oyad by the federal goremmerd In the pmcUca of your pmfauslon cmos you/ Pennsylvania licence or certificationlapsed or since you pieced Non Inactivestatus?

I vrn1r that this êppllraUon(sin thefllnai lamiat as supplied bythe Depetient vlStáWand has 101been ahloradtr otherwte nodmed Inanyway. I Sm SWStO ci the c4mlnWpsneJfäe for tempering with puIle .icwda or Informationqridar 18 Pa. (2.6. 5 4911. I vartfr that the sbtwnonb In th oppUceUoçiare fla oridmctta the bustormyKnoWados.InfmmadoriandboUef. 1understandthatfalseclalamenlaera made subjectto thopenalties of 15Pa 0.5. § 4DU3(relatingte unawom falslttation to authorWca)and may rawh h the auspenslon, mvnllon, or Oslo) of m lnae ceWflcew, permitormotmfon.

Signet a of Licensee Date

4 Attachment B (Part 2) PERFUSIONIST TEMPORARY GRADUATE -

• .. •

•

‘tomi&oit ‘• •

Child

•

Supervisor

Board/CommIssion: Certification

Application

Obtained Uéensë

Evaluation

•‘ Appilcallon

rQlNanie.

; - . - . •

• .

Abuse •.. ‘.

lype:

•

By: -.

•.

results: .

Fee

•

Aiwlication

•

OsteopaThic . ‘•

•

education

Wthsile;--

wpwvèd on rc hñe lecfrpnically 3urau. 3ourse icensuivcetfiflcaüon.-A

all

directors pftheChildProteôtive

you oth Veterinary Osteopathic

All iiipevisor

An Coplete Otaduate llceüse. H”

Temporary authorization

esrenon-rthndab1e.

older

DCW practice çen If certain be

iot.coripleted

Thniporaiy

the

persons

required

this

heaLth-related.license

requfred.Jf

apphcatcm

&eapplyiñg

completed

application

issued Perfiionist+1éc(ld9

nyofthehealth-mlatèdboard(exceptthe topic

using

tha.

apphci

For

sections An

+Texflj?ofOS’f

are:coñsidered

training

providers

Perfiisionistlicense

Secti

Medicine)

for

apply

Provisional the

that

application to •

the

Medicine

Gmdbatt

submityoiwnamë,

license,

days cømple ficrn chjld complete,

within

Commonwealth

applicable, the fee

réaAon, infprthation

and

for

ng•for

1.oftht

required ofWrn

the can from

abpserecoghiffoh

dad a

resubmit

not

Temporary one

ion certificate;

Perlhsionist

SeEvices

application

ts4

Perflthiôni

fee

it issuance

from “mandatozy;eporteñ”

Depàtent

Hat

the

completed

1ao.oo

year, found Vc

background

oc$1s

ceitifióat Iions’ i

imperative

cowse, provided of

re4thed

date

Section

cndition

the

aöd

the

ficationtàActasa

DHSrapproved

ofPennsyltaniaunffl

Law you

date

State -

registration,

Graduate

cuew.ic-

application

fiJi

and

Form

the

withIn jj

license. issuance.

wilike

reqt’

t.This (23P.S.

for ,•

on.your •

holders

OsteopthicPeitsioñist.

initial

Board

sppthng

check that

Rummi

Depaflmcnt approved

attehdancè

Osteopathic

and

Uceñsü’e, •

reporting.

six

you

Pntibnist.

required

Pkase

:for

license.or

§6311). of

forwáxd

documents

fee. If and

application-fr

permit,

child

mOnths,

bnly

under

Soñices

:‘j

Fim

this

j*n

State

the

providür

You &neml Supewisbrfor

docume$s

note

etc. required àf

abase

application

Aaer

Oèteopathic

ral

section

you

Temporary

hours or flerefore,: to *

Boardof

Slate a

may

certificate

updates

complete

for

lic Directors that

(DHS.

your

cannot

hàye

will

the

ydu

éde

the

not

of -

all

6311

will

a 1W3W01B j ‘.CbeckustNAmç L •‘ Thsfrucions ‘, ProvideareEeniCdniiñal 3rds Check (CNRq tam ‘ thçhate policeor othã stateagencythatis the official

. rçoiftoq/ for criminal ‘hlstozyrecord information for every. “ ate in whichyouhave live4 worked,or completedprofenióna! . . ‘ ±aininstudies.forthejastfive(5)yeárs. ThSrepöd(s)mustbe . ‘• ‘ datedwithlif90 daysof thedatethe applicationis submitted.For • appUcantsliving,working;or completingjráining/swdiei in ‘. ,-, Pennsylvania,yoüECHRCrequestwill.je automatically : subthiftédto the PthusylyaniaStatePoliceupon submissionof

: ‘ thisapplicEdon.The’PAXCHfeewill be included at checkout.

. YburPA CHRCwill be sent directlyto the Board/Conimissjua Youwm’benotified if additionala tionisrequired. For

- individualsliving,’working, or completingtmining/studies ouide CiinhInd’flisto‘ t. 9 ofPennsyivaniaduringthe p4st flit (5) ycar,in Ecu of obtaining • 9iCck- - ]ndi3ddualflte background checks,3’ónny elect toproi-idè . QW a staCIWC from thestatein whichyou cwtehtly reside, • MQDyourflI Identity HistOrySnmwnrSrCheck, avAilable jflps://wwThLgØWsen4skjisfidefly-histopj-swnthary. ohdcs.

. - Pleasenote:Fàr applicantscurrentlyliving,Working,Or “ completingfraliilng/Studies•k CalifcmkAfizona, OrOhio: Due . .otle ]4wsofthésè states,the Bpard is not an eligibletecipintof

. -‘ CHkCs OjyowRC willnOtbe issud to yon for upload tothe Board.Please obtain your FederalBureaUof hwesdgation (FBI) - “ [denfityHlstàsy SimirnsTyCheck,qvailable‘atthe ibik noted

. abdve.. ‘‘ . - Frrn4&a àcial nofifl&tion of infonnatiou (Self Queiy) from ‘ ‘ jieSafional PmtdtoherDataBnk. PleEserefer to the NPDB’ ‘ for additional information.When-youreceive the Databank Report wèbsité online“Re,onsó to 3ir Self Quer”you willned to’upidadIt tóyour’ applipation.The ztpoft will zféedto be uploaded, where ,rompted, in order to submit your applic$iozt

. .‘ ‘ CdmplefeS&donl of the VefificafionofPerfaisionlstEducation: Education. Cornand foiwar4 to your schboifbr completion‘ofSection 2.Thó Verifitidon dgrath müátretn the óo lewdverifiqatiOndirectly to the ., ,‘ 1013112019 jclwdflt Naie Insuacifons

• Contact theABCP or dther Nationally-recognizedceri4’ing • .. ageny and nquest’an official veñfióafipnthat you are eligible ypgUu%jw —have appliedto sit fbr the certificationexamináffdn to be bent ‘. Jirecilyto the Boart This is onlyrequired if you are applying for aTernponry GrsflnatePerfizsionigtor Temporaiyprovisional • . erfiisiqtht liceflse . C&aàEti licensingautho ities of the elates,tenitoñes or • .‘ ounb’ieswhe±eyod holdo; haveever held a license, certificate, . permit rçgistratjonor other authorizationto practice a health profession (whether active, inactive,expired or current) Letttr of Good related and request letters Ofgood standing/vedficadonof licensurá in; StaUdin a ocs’ ¶ ‘. hat state orjurisdicdon. The lettetmustinclude the following: Licenseissue and expiration date, licensestatus (cunentor expired)anddiscipliziary standing. The letter(s) of good : tandingmustbésentdfrecflyftthe$oart

• iou will need to uplàa4, where pmmpte4 pmótof professional .. [labilityinminuce covenge through self-lthwance, personally wc!iased nsumnce or insurance providedby your employer for Malpractice theminimum amohS of $1,oôo,ooo.ooper occu ieee or clalins Insunnee made. This prpof of Insurance/certIficate must inclUde ydur name and indicate that you are covered under thlspoflcy whileperforming perfusion servicegin theCommonwealth of

.. Pennsylvania. .

• ContadtheAmèrican Board of C&dioi’ascularPexlbsiov(ABCP) qr otherNafiotally-recognized certifyingagèñàyand arrange fir Certification • . - ‘our”credentialyeñfication”to besent dfredlly to BOaRd. Please e qiload a Currkülüm VitaWflesumelisfin jfl periods of or unemployment (i.e., child rearing, etc.) :. mp1oyment reseafch, frornflduaflon from your highest level ófeducahoñ to preáent Resume/Curriculum (the education completed which.qUalifiesyou for this license), Vitae The list must be in chronological order, includingthe name, City . and state of the employer, dates of employmentDradvanced

, ducaton/flanin.g finälüde the month andyJ3 at description , . .. ofthcprnc&eacfivit , C. r TOI3IMDIP II Evaluation resUlts: BoirdCommlsslon: Osteopathic i.(ethcthe

• License 1)’j,e: OsteopathicPerfusionist 1’1e46R1”f Obtained By; Application kloøPj

CheckListNjme P InstructIons.

. If this applicationis notcompletedwithin,sixmonths,ppdatesof

. • certainsecifonsof the applicationand supjorting documeiit will

. • Screquirqd.If applicable, background check documents cannot be

. older that 90 days from thedate of issuahcç.If this appliction is

: 4ppflcaffon iot completed ithin one year, you will beitqufred to comjilew a• . • riqplicanon and resUbmittheapplication fee. You may not •cein the Commonwealthof Pennsylvaniaiinfflyoü have . pnct . been issued a license, certificate, registration,permit, or . süthonzaffon Anapplicationfee of S5(is required for OsteopathicTemforwy . GraduatePerfimiónistlicensend fizUOsteopathicPerThsiónlst Application Fee hcense. An applicationfee of , is ±e4uiredfor TheOsteopathic TemporaryPmwsional Perfüsionist license.Please note that all . fees are non-refundable. .00 . .• .. • 8 . Cóniplete Section.1of the VefiflcaUon.to.Actas.aSupen’isbr for Cerifficadon of aTempcnry GraduatePerlbsionist Form andforward to your

Snpenliàr . supep’isoifw completion of Section 2. flis is bi4 requfredif . . you tè applying for aTaporazy GraduatePethisionist licnse

. • 411‘health-relatedlicense&cerffflcatè holderSand fimera dfrcqtorsaretonsidered “mdntoiyrcporters” under section 6311 .

. of the Child Protective Services Law (23RS. §6311)...Thereffizv,

. . -. . ll persons ppjlying for issuance oft initiallicense or certificate

. • from any of the heákh-relatedboards (exceptthe State Bo&d or Veterl. Medicine)or from the StateBoard of FatheralDirectors ire required to complete, as a condition of licensure,3 hours of Ak approved trainingby the Department of HumanServices (DUS) . ZWUSC CE Chil ii onthetopicdfóhild busóretowñtionand.reporUng.Afterydu . . iãe completedthe required course1the approvedprovider ivill ilecfronicalfrsubmit your name, date of attendance, tc. to the . . 3Ureau.For thatreañon,itis imperative thit yourógister for the I •. càrsè using the infomiaffoliprovided an yomaplica&ji for

• IicensurWcerfffiction.A list àfDHS-pyruved child abuse : xlucalidnpmviders can be flrnndontheDqarthentofstnte

‘ .: .. • Websilá: •

413 40131/2019

[ CbcckListName I . Jnstrucffdni *

... . frrddde I iecent &irnrni lflsweRedoids Check flac) m : (thestateoljce or otherstateaen’cythat is the.offlcía! . . repósltorylbr criminal history record infoxmidon for every

. statein which you have lived, workcd, or completed professional . ••. . aining/studies.forthepaatfivé(5)years. The report(s) must be datàd within 99 dayi ofthe datöthóapplication is sobmifted. For applicantsliving, working, or completing lraanmgfsm&esin

. Pemisyivania,your CHRCreq est will be automatically submittedto the PennsylvaniaStatePolice upon submission of

. his plicaffd4. The PATCHfee wiUbe inclwlo1 atcheckout ‘ . . YourPAQC wll bi sent dfrect to the BoarWCothmisaion. YouWillbe notified Wadditionálaoffdnis required. For brln.inaifllkto individuAlsliving,working, oicomplethg frdining/studiès.outhde ‘3’ PthfisyWaniaduring the past five (5) yean,ln lieu Check of Oiobriinjng . ndiyidual state.backgroundchecks,)knzmay .electto provide . 30Th a state.CHRC from thestateiá which you cmrenUyreside, jSjqij you FBI Identity Histozy Snmmnry Check; avaalableat i1vs1/(ww’eyfbigovJrnce/cjisfidenthy-lustoiyjjy .

. theckE. . . ,.•

: •. Pleasenote: Foi applicants currenilyliving, working, or : : completing fraiizing’studiesin ?alifomia, Afizona or Ohio: Due . . to the Jawsofthee states, the Boar4is not an.digibje recipient of

* Will . . CHRC’Sor yrniCflRC nat be issued to you for uploadto the Board Please obtain your Federal Bureu of kvesbgauon (FBi) IdentityThsto available at the noted . inaThect ; li thdve. . Prviiwi ÔffiØi nofi cadon of ihformatioñ (Self Quay) &om -. te Nátjànal Pncffdoña DatajBank.Pleasereferto the NPDB, •• addfflonaHhformation,When.you Databnk Report wihsitä fbr nceiñ the a your Self Quezy” you will nee4 to uploadit tâ your . ,bline aplicatoa The cpOft will rd to be Uploadcd Where .. ?rompted,in order to submit yoá app&siion.. . . ,. CómpletSécdon 1 dfth&VdflqadonofPerfiisidiijsg Education EducatiOp [‘mmand forward to your schbolfor compi tion bf Section2.The

- Vcflfltaffon . roram must return So complete4veñficaffon directlyto the . : .

213 1W3W019 Name_jj bwfrucdons (_CheckList U CbnthcttheABCP otothãNonHY-recoized.c&fifig . agency and request an official verification that you fle eligible

- andhave appliedto sitforthe cttfificadoñ Exam Ehthty.. .. examination to be sent directlyto the Boar& is s only requiredif you are applying for • a TemporaryGradnatePethsionistór Temporary provisional . pethsiOnist license.

. Contact the licensing authotifiesof the states, tàrritodá & .. crnmftieswhere you hold or haveever held a license, certificate, permit regisfltkin or other authorization to practice a health relatedpitfession (whetheractive, inactive, expired or effluent) T-• (3 d and re4uest letters of goad standingNcdfication g of liceulure in a ‘ that thtc oIjithsdiction. Thc.letterxáust ihólude the following;

. . [iceniç issue and expirationdate, liceáse st4tus (current or• çpfrdd) and disciplinarystanding. The letter(s) of good to . .. ;tandlpgrnustbe sent dfrecdy tbç Board.

. Yoi will need to upload, wherep olupted, proof ofprofessional

. . liability insurance coveragethrougfrself4nsurance, personally

. . ,urchased insurance or insurancepruvided by your emPloS’erthr Malpractice the linimum amount of$1,00D,000.QOper occunence.or àlaims insurance made.TMS.proofofinsurance/cerfiflcatemustlncludeyoiar name and indicate that you are covered under this.polléy

. while pei’formlng pêrftsion services In the Commonwealth of .______Pennsylvania. . . Contact the AmericanJoard àfdar&ovascular Nati al Perfiision(ABCP) - other Certification or Nationally-recognizedcerdiying agency.and arrangeThr , your “credential verification”to be.sent directly to tie Hoard. . Pleaseup]od a Cudmilum VtheurnelisthgjJjperiodá.d’. .‘ empidyment or uhemploytwnt (i.e., child rearing, reedrch, eta) from graduation from your highest level of educationto present. Resume/Curñculum (the educationcompletedwhich qualifies you for this license). Vitae The list must be in chronologicalorder, includini the name, city ! and state of the employer,dates of employthent or advanced edçcdtioh/frainin (thclüde the month and y), anddescription . . - Dfthepmtflceacffvfty. .

3,3 •

• Child

Supenisor

Certification

AppflëalionFeè

Board/Commission; .______

Obtained Uce’me .

Evaluation .

kpplieadon

• .- .

fleèil4st Ab %. .- ‘ . - •.

Tpë: •:-

By:

•

rcsultt CE -

Name] -.

Application

Osteopathic - -

,authoizafioi

èducationprovidtrs

cour

electronically

Websile: have

approved

ale

BureAu, iccnspr&ceftifiôafion.

all fr ôfthechild&ótecffve Veterinary

threctors a supervisor

OsteopathicMedicine Complete

you

frnporary

;kense.

4n Graduate

older eesatenon..xáfrndable een bracdce

if certain

be zew

Temporary

penons.applying

reqüire4-to

this

health-elated

teqdired;

application

are

completed compl&ted

any

application

issued

Pàfijsionist

topic

using

than

ajthcflon

For

applying

Au sections

are

training-by

Perfiisionistlicense

Mediciçe) Secuon

for

nxcoj

f 90

Pmvisionai

that the

the

appic4ton the

cozidered a

Graduate

submit

child completion license,

days

complete,

Commonwealth

within

the health-related

applicable,background

fee

infbrrnaflofl

reañon,- -

and

for

licenss/ctcatd

required is

canbë

the

from

abuse

for

yqur the

resubmit

not

Mist

‘tirnpo(Ni

$8t1u

RaSsri.

Temporary

certificate, one

Set the Pethsiomst

- application

Pethsiomst

fee issuance it

from

“mandatory

Department

the completed

name,

ncoon

found

Venficaton

year,

ices of

imperative of course, protided

required

date

Section

condition

the

boards

95.QQ

and

DHS-appmved

the

tñicffons

Law

you

date.ofattwidance,

on of

SWtè

registration, of

Graduate

is Mi Peimsylvania application

and

Foxm

the

license

within

issuahce rep will

required

(23;P.S. 1r.R*4rcnCs-t

(eçcept

for

ho1d

Gni&o4

Osteopathic

initiaj

BoardofFuñeral

supporting that

Deparbneñtofsaie Human

approved check This

orte&’

dng.

your be

Qsteopathic

and

Act

licenswc,

six

you

Peribsionist

required

Please

-license

the

for

forward

application If and fee documents

child

permit,

months,

only under

6311):

Señ’kes

this

until a

State

provider

the

nera1

Supervisor

You

documents

Perfiisionist

note

et. required abtse

After

-Osteopathic

application

‘• r1sic

section

you

Temporary

hbdriof

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Board to or

éerffficate may

updates

to kr complete

Directors.

(OHS).

license

that

your

for

àannotbè

have will

th&

you

the

not

all

of’ if

6311

for

- will

is in

I 1

10131(2019 r.cbakLhtNenie Insirucfionà :: . j (PIbVI&a recent CrithInâlHistàIy Reáádè Check•( CD)from

. •. theätatàpolice or dtherstate agencythat Is the official • repository for criflthzaThIstotyrecord information for every . .. itatê inwhichyouhavelived,wozked,or completedprofessional . iraining/studies.forlhèpastfive(5)years.The report(s) mustbe . dated ithin90 daysof the date.tbeapplióàtionis submitted.For . applicants.living,working,or.completingfrdiiiflg/studiesin

: nàyiynnia,your cime requestwill be automatically .• mbmiftëdto the PennsylvaniaStatePolice upon submissionOf thisapplicafidu.ThePATCHfeewill be includedat checkouL : FourPAcimcwiube sentdirEcdyto the Bóard/Commisthoh, . YOu*111be notifiedif additionalácdon i&required.F& bdMduø living,working,or completingframing/studiesoutside • “ )fPennsylvamaduringthe pastfive (5)years in lieu of obtaining . individualstatebadkmund checks,ybu may.electto provide • BOW a tEte.CiWC ftoththe statein i*’hichyou cunenfly reside, • 41Wrow FBI IdentityHistorySprpmmyPheck availableat

. ft/IwwfhigSv/seicèsicBsIideutW-histoxysimiàxj_ checks. . :

. Pleasenote: For applicants.ouirentlyliving,Working,or complting nining/Etudies in California,An a or Ohio: Due

‘ tothe ]ivs ofthese states,the Board is nQtan eligible recipientof . .‘ . CHRC’sor your CHRC wiUnöt’beissuedto you for upload to.the

.. . 3oârd.Please obtainydur FederalBureu of Jnvestiiafion (FBI) . . 14HistorySumma1yCheckvaflableatthelithnoted . .. 3bpve...... Providean officialnotificationof infànnation (Self Quely)from . . the N’adonalPraetdoiietData Bank Pleas&rdferto the NPDB websiwfor additional information.When you receive the D• a K tabák ‘Rcsonsdto.3iouESelfQue1yyouwillneedtouploadfttoyour , onlineapplication.The reportwillneed to be uploaded wher rompted, in order to submityour apphcon.

. : . complefe Secion I of the VerificationdfPerfiisionistEducation Education ftjn fbrward to your schàolfor completionof SectiOn2.Thc Yerifl&lion rog must retUrn 11wcompletedverificationdhvctlyto the, . .. ,oard...... 1Q131.2019

. . H I CheckList Namel . Jns(ructtoñi

• Cbntâct the ABCP or other Nalionàily-rècogniz d certifying.

. agency .aid request an official vefificaffonthat.you arSeligible ad have appliedtá sit for the éefliflcafionexamination to be sent Exam Eli bili ‘. irectIy t TheBoatd:This is only required if you are applying for

. Tempomiy Graduate Perfimionistor Tempomiy provisional

• ,erfiEiopist license. •. Contact the licensiilgauthorities of the states, ten*ofles o countries whereydu hold or have.ever held a license, certificate, .• ,ermit, registrationor othr apthorizatiohto practice a health relatedpiàfession (whetheractive,.inaëtive,expired Lette of Good or current) and request ledeis of goad tandhigJveriflcâtion of liceñsure in • g ‘ that state orjwisdicbon. The loner must include the following; . . liowiseissue and ekpkation date, license status (óurrent or

• expired)ad disciplinary standing. The !ethro) of good

: tanding mustbe sent dfrectlyto the Board.. Youwill need to uploadj where prompted;próofofprofessional

I habthty msumhce coveragethrough self-insurance,personally purchasedinsuranceor in12ranceprovided by your emp1orer for . MaJpracdce thç minimuhiamount.of$ 1,000,000.00per occurfence or claims Insurance made. This proof of InsurañcWcerdflcate mustihclude your

• name and IndicAtethat you are covered under this oliey .. whileperforming perfusion services in the Commonwealth of

?ennsylvanla. . g Cóiitactthe AmericanBoard ofDardiovascUlarPerThsidn(ABCP) . or OtherNationally-recognizedcertifying agencyand arrange for • your ‘‘crdènila1verification”to be sent directly to the Board. PleseiiploadaQ e16ñgflpSfldds of • employment or unemployment(i.e., child rearing,research, etc.) . from vaduafion fim yir NeEt level of edutaflonto àent Resume!CunlcuJum (the educationcompletedwhich qualifie youfor thislicense). Vitae The listmust be in chtonOlogicalorder,’includingthe name, city . and stateo’the employer,dates of employmentOradvanced ethication/frammg,(rncludethe month and vat), and description ofthcpmcticeacffvity. , . . .

3m PERFUSIOMST TEMPORARY PROVISIONAL iW31t2D1O

Evaluationresults: - Board/Commission: OsteopathicMedicine License lype: OsteopathicPerfijsionistk1écft(9 (àL&_(f4SV\54 Obtained By: Application: jwij ± oaQ CheckListName Instruct ons I if this applicationis not completedWithinsix months,updates of

, certain sectionsof the applicationmidsupportingdocuments will berequired.)f applicable,backgioundcheckdocumentscannotbe alder than90 daysfrom the date of issuance. Ifthis appljcationis Application not:completedwithinone year,ou willbe required to completea

. ew applicationand resUbmittheapplicafignfee. You may not

. zcffcc in theCommonwealthofPenn’ltaniaunth you have

. . ben issued a license,certificate;registration,permit,.or uthorization 4n applicationfee ofSSWIs requfredforOiteopathic-Temporary

. GraduateP rfiisionist.licenseand’Ml OsteopathicPedbsionist 4pp&adon Fee licthsc. An applicationf of4fl requiredfor the Osteopathic: . . Temporal-)’Provisional Pcthsionist liqense.Pl6asehotè that all

. feesare 00 . non-refundable. gq CoffipleteSection1.f the Verificationto Act asa Supervisbrfor Dérfificaion of a TemporaryGmdäatePerThsionistFormandfoiw&dk your Snpuvisor npeprisor Thrcoffipletionof Section2. Thisis bulyreqwxvdif

‘ ydu&e.applyiñgfor a TemporaryGraduatePe±sibnist license ‘. Ml health-i-elatedlicensees/certificateholdersandfimeral iintom are-considered%andatory.reporters” under section 6311

. ofthe ChildProtecffve ServicesLaw (23P.S. §‘631l). TherefOft,. . . . 1J parsons applyingfor issuance of an Wti4license-orcertificate .. 4cm anyof thehealth-relatèdhoards (exceptthe State Boardof VetednaiyMedicine)or fromthe State Boardof Funeral Directorp are reqdred to complete, as a conditionof llceñsure,3 hours of approvedtahiing by the Depirtmpnt of HumanSeñiccs (mis) Child .Abuse CE on the tOpicof child abuse recognidoh an4:reporting.After ydu-. havecompletedthe required coune the approvedprovider will

. •lectrqnica1lysmft your name, date of attendance,etc. to the Bureau.For.thatreaion, it is imperativethatyou registerfor the •- course using the infomiation providedon your applicéfion-r

. llccnsurc/certiflcation.A list of DHS-approvcdchild abuse - : .. educationproviders can be fbund on TheDepartmentbfsfa.te

. . . Websit& - ..

In 1013112019 CheckList j Nàmç fi, Thstrucflons ! frvi&a recentCnniinAlThstozyRecord Check (CHRC) from the statepoliceor otherstate agency is the . that official

. repository for criminal history record nformaflon 11wevery

‘ statein whichyouhave lived,worked,or completedprofessional inrWnidies.for the past five(5)years.The repért(s) must be lated within90 days of the datethe applicationis submitted.For . ippllcants.living,working;or completingfrátñng/sthdiei in .. ?ennsylvania,your CHRCrequestwillbe automatically . subiniffédto the PennsylvaniaStatePoliceupon submissionOf .. . this application.The PATCHfeewill be includ&l at checkout

• YourPACHRC will be sentdhtcfly to theBoard/Cothmissjon, . YouWillbenotifiedif additionalactionis required.For mdrnduals living,working,orcompletingfrainmg/stidies outside

• criminal Thstory Check ofPennsylvamaduringthepastfive(5)years in lieu of obtainjng . individualstate background checks,you may elect to provide . •. BOTHa state.CNRCfromthestate in whichyou cuirently reside, ANDyoiixFE Identity Histàiy SummaryCheck availableat . flps://www.fli;gov/seMcewcjisrt&utity-histo-,

checks. .

Pleasenote: applIcants . . For cufrenflyliving,working, or completingfrainkg/s udiesin California,Athpna or Ohio:Due •. o the lawsof thesestates, theBoard is notan eligibletecipièntof . CffflC’soiyour CIWC will nOtbe issuedtoyou for uploadtothe. Board.Please obtainydurFederalBureau ofInvestigation(FBI) • . IdentityHistory SurnmaxyCheclç availableat the link noted abive.. . Provide a officialnotificationof informa&n (Self Queiy)from theNationalPmdfifioherDataBank. Pleaserefer to the NPDE wôbsitcforadditional information.Whenyoureceive the I)a U “Responseto 30th SelfQuer” you willneedto upload it to your nline application.Thereportwillned thbeuploaded, Where . . ,fornpted,in order tOsubmit yourapplication.

. CompleteSection1 of the VerificationofPerfhsionist Education &ducatton. form andforwardto yów sthbol thr completionof Section 2.Thé Verification .. pràgrammust rtum the Oompletedverificationdirectlyto the :.

213

. •

‘. ;

Vitae Resume/Curriculum

Ceñlflcafion •

Naff loninole .

insurance Malpractice

Stàndin

Letter Exam F .. . .• .

. Cbeeldist . ..

• of .

. g . .

Gâod

: p ‘ .

. Name . . ‘

. : ..

and

(the

educaio&trining

The

your

or .

orngaduafion

mploymeut Please Contact

üine

!ezrnsylnnia..

while

ftheyncffce

liability

2ade.

the standing

purchased

You

expired)

license

that

and

:elated

countries J(

Contaàthe

DenIt,

and

dir

agency

Contact

eTfl3siQfliSt

other

Temporary

state

education minimum

list

re4üest

will

state

cily

have

credenualyenficaton

performing

and

upload

This

must

Nationally-recognized

the

pmfession

issue

insurance rcgisfralion

and

need to

the

mustbe

whereyoü

inkurance

applied

indicate

the

American

proof

the

jurisdiction.

letters

Iicensin

request

ABC?

license:

disciplinzy

and

aCudculum

activity.

amount

completed

Graduate

employer,

unemployment

Boart

from

upload,

finófude

expiration

chronological

coverage

perfusion

sent

(Whether

dfgoöd

that

or an

insurance/certificate

sit

your

hold

of$

Bàard authorities

This

other

insuiance

PerThsionist

directly

official

for

you

which,qualffies

where

dates The

standing.

1,000,000.00

the highest

VitaelResume

standing/verification

the

Insfrucdons*....

th±Ougb

active,

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sit for Z4 Evaluation results: BoàrWCommission: OsteopathicMedicine License 1’’$: OsteopathicPeribsionist &no(tk1Ij Gø’kv& Obtained By: Application 4

Checldist Name iicftçns I

• if this applicafionis notcompléted withhi six months, updatis of . certainsectionsof the applicationandsupportingdocumentswill

. berequired. If applicable, background ôheck documents•cannot be older that 90 days from the date.of issuancç. If this application is ApplicatlSn not completed within Oneyear, yowwill be required to complete a • new application and resUbmit application . the fee..Ydumay not practce in the Commonwealthof Pennsyhvaniauntil yodhve beenissued a license, certificate,registration, permit; or •. authorization An application fee of $$6’mrequired for OsteopathicTemporary

. Gmduate.PethsiOnist license.andMi Osteopathic PerThsiOnist Application Fee license. Au pplication lee of$0 is i&juired for the Oàteopathic

. TemporaryPtdvisional Pethsionist license. PIasenote that all . fees arenon-refimdRble. .2. 00 . COmpleteSection 1 of the Verificationto Act asa Suporvisbrfor Certification of a TeinporazyGradUatePedbsionist Form and forwardto your SupcMsor supevisoi for completionof Section 2. This is Onlyrequired if

• youare a TemporaryGraduatePerfi]siUnist .li applying for license health-related licnseê/certlficati holders and fixheral ±rec.tursareonsidered “màdatory rqportcm”tinder section 6311 of the Child Protective Servi es Law (23P.S. §631l)..Therethre, - allpeisons applying for issuance of at initial,license or certificate - from any of the health-relatedhoards (exceptthe StateBoard of VeterinazyMedicine) or from the State.BoardofFnñeral Directors . are required to complete; as a condition of licensure,3 hours of approved training by the Departthcnt of Human Stñices (DHS) Child• Ab se CE çñ the topic Ofchild abuse recognition and reporting.After you . have completed the required course,-the apprnvedprovider will elecfronicallysubmit your name, date of aftendance etc. to the . Bureau.For that reason, it is imperativeihit you rd&swrfor the course using the inforthadonprovided on your ajplicaPon for licensuré/cerffflcaffon.A list ófDHS-approved childabuse . education providers can be fdund onthe DeparthientofState Websiti. 1Of31i2O19

CheckList NAmç . Instructions 1 j[ I, Provide akct tiininálThstoijR&ords ChecktCIUtC from

P. - the stateo!ice or other.stateagency that is the official

‘. . repository for criminal history record infoimation for every state in wfficliyoühavè lived,worked, or completed professional aining/studies.foftle past five (5)years. The report(s)must be datedwithin 90 days of the datethe applicationis submitted,For . . applicants.lhdng, working;or completing fr ining/studiesin Pennsylvania,your CHRC requestWifl be autornatica]ly submittedto the PennsylvaniaStai.Police upon submissionéf thisapplication.The PATCHfee willbe inclu&d át checkout. . YourPA CHRC will be sentdiiecily to the Board/Cogimission. YouWillbe notifiedif additionl actiOnis required. For flic individuAlsliving, working,or completing training/studiesoutside

. )fPennsylvama duringthe past five (5) years; rn lieu of obtam3ng Lnthyldualstate backgroundchecks,you may elect to provide . BOTh a state.CHRC from thestate in which you cmrenilyreside, .. jgjjpffl Identity Histhty Summary Check, availableat Lftnsf/www.ffitgov/servic&qis/identty-hitczysuutnwy

. checks.

: . Pleasenote: For applicantscufrenflyliving, Working,or .- completing training/StudiesIn Califpmia, Añzona or Ohio: Due tothe lisvs of thesestates, theBoard is not an.eligibletecipièntof cImC’s or your CflRC willnat be issued to you for uploadtothe

. . Board.Please obtain your FederalBureauof Invdsdpton (FBi) ‘ [denfityHistory Summaly Check,available at the link noted thøve. ?rovidean Officialnoiiflcátionof information-(SelfQuery)from .. . theNationalPracflfithierDataBazt Please refer to the NPDB wôbsitäfor additionalihfoimaUon.When.you a a IItPO. receivethe bk “Responseto jour Self Query you will need to uploadit to your . Dnlmeapplication.The reportwillneed to be uploaded,where . prompted,in order to submityour apliôtion.

• CompleeSection I of the Verifipationof PerliisiànistEducatjojj Education x and forwardto your schoolfor completionof Section2.The Verification program must returnthó completedvefificaflondirectlyto the

. - I 1W31fl049

(_CheckList NaEe_jj. ‘ ‘ Instructions : ContacttheABC? orôthèrNagonally-recognized;c.enijijing

. agencyandrequestanofficialverificationthat you ‘areeligible, . . . and have applied to sitfor’thece±tificaffonexaminationto besent •Exam Eligibility directly to the Boar& This is only required if you are applying Thr ‘ a TempomGmdüe Peisiost or Tempora provisional

. ,erfiisiónist license. , . Contact the licensing authoritiesof the statds,territories or . , •. countries +here you hold or hayeever held a license, certificate,

. permit regisution or other authorizationto pra,çticpa health active, I. ° related profession (whether inactive,’expiredor cwrent) and request letters of goad standingNedflcafion of licensute in fl OGS“ “ that state Qrjufisdiction.The letter mut iholude the following: : ‘ Lice issue and expirationdate, license status (current or .. .. eicpfred)and disciplinarystanding. The letter(s) of good

. standing mustbe sent dkedify to the Board. : Youwjll need to upload,wherdpiompted, pmofofprofessional ‘. liability insurance coveragethrbughself1nsurance, personally

. insurance or ilsurance provided . by , purchased your employerfor Malpractice the minimum amount of $1,OOO,OOMOper ocminence or claims

[nsnrance . madà. This proof of insurancWcerfiflcate must include.oür name and Indicate that you are coveted under this poliéy

‘ while peiforming perfusion services in the Commonwealth of

‘ ‘ Pennsylvania. . .

. Contact the AmericanBoard àfCardiovascular PerfUsion(ABCP) or other Nationally-recognizedcertifying agency and arrange for Cerifflealion your “credential verification”to be,sent directly to the Board.

.. ‘ , Pleaseupload a Cuáiculum Vitae! eswfe lisdngpeflodwot r empidyment or unemployment(i.e., child rearing,reearch, etc.)

. . . ‘ trorn gta&afion from your highest level of educationto present Resume/Curficulum (the education completedwhich qualifiesyou for this license).

Yltpe . The list must be in chronologicalàrder, includingthe name, city and state of h& employer,dates of employmentor advanced , , educdfloh/fraining(includethe month midy). and description —. of the practice activity,. . . -

3,3 toninow Dt4ly 11 ‘O&’A

• Evaluationresults: • Board/Commission: Osteopathic Medicine License e: OsteopathicPerftsionist - 1n p’j er Obtained By: Application -i’jkiç&oc’..j tzSsfo qr-snr&

ChetkLlst Name J •. Jrnfructions if this applicationis not completed within six months, updates of : • certainsectionsof the application and supportingdocumentswill e required.Tfapplicable,backgroundàieck documents cannotbe . olderthan 90 days from the date of issuahce if this aplicafion is Application lot completedwithin oxe year, you will be requiredto completea . new ajplicaffon andresubmitthe application fee.You may1not

. practicein the Commqnwealth of Pennsylvania until you have teen issued a license, certificate,registration, permit, or • •. authoiization 4jL.j5.QQ

‘ 4n’appliatiofl fee of $8flhireqülitd for Osteopathic Temporary

. Graduate Perfimibnistlicense and.ThlIOsteopathicPedbsionist 4ppliè;lionFee License.An apjilicafionfee of W is required for the Osteopathic ‘‘ . TemporaryProvisionhiPéribsionist licensç.Please note that all • fees sic non-wThndable. Complete 95. 00 Section 1 of the Veflfiôationto Act as a &pervisbr for

, Certification of a TemporaryOraduatePethisionist Fonxiand forward to your Supervisor supervisgrfor completion of Section2,.Thisis only required if • youare applyingfor a TemporaryGraduatePerksionist license

• Allhealth-related licenseeskerfifcati holders and fimeral direcjors areèonidered “mañdatoxyreporters”under secflon6fll • , of the Child Protective Services Lav (231.5. 6311). Therefore,’ ‘ ‘ § qflpersons applyingfor issuance of an initiallicense or certificate , . from any of the health-relatedhoards (wçceptthe State Board of VeterinaryMedicine) or fromthe State Board of Funeral Directors . ‘ are required to complete, as a condition of licensure,3 hours of approved training by the Depatbnçnt of Human Serikei (DHS) A’ , Child. . 9$ CE on the topic of child abuse recognition and 7eporting.After you

: ‘ na* completedtheréquired coume,the approvedprovider will electronically submit your nathe, date of attendance,etc. to the . Bureau.For that reaon, it is imperative thatyou register for the ‘ , course using the informafioh pro’fridedon your application for licensure/certificadon. A’Ustof DHS-approvedchild abuse .• . educationproviders caa’bë found on the Departmeñtof State

•• . Website;

• .• in 10f31!2019 ksfrucdons —. rchkistNai ft Providea recent CrimInhiHistoly Redords Check (CEEC) from

. the statSpoliceor otherstatSagencythat is the official • repository for cHmlnal.Mstory record information for every statein which you have lived, worked, or completed professional . fts&ng/stuthes.for Thepast five (5)years. The report(s) must be . thted within 90 days of th date the application is submitted, For applibantsiiving, working;or.completingframing/studies in . Pennsylvania,your CHRC request will be automatically submifféto the Pennsylvania State Police upon submission Of

• this application.The PATCHfee will be incluckd & checkout.

. YourPAClmCwiflbe sentdfrêcfly to theBoard/Conimission. Youwillbe notified if additional action is equfre& For living, wQrking,or completing Criminal Ølsffi individuals framing/studies outside kak of Pennsyl’Ganiaduring the past five(S) years, in lieu of obtAining ‘ indiyidualstate backraund checks, ou my elect to provide . BOTHa state.CH CDfroth the state in Whichyou currently reside, AND yourFEI Identity HIMbIySummRry Check available at

. J3p://www.fbigov/sewicesfcjisfidenthv-histonjjçy- checks.

. Pleasenote:For applicants cuirently living,Working,or . complelingtraining/studies in California,Mzon% orOhio: Due tothe laws of these states, the Board is upt an eligible tecipiént . of ‘ . . CHRC’sOtyour CXIRCwill net be issuedto you for upload to the Board.Please obtain your Federal Bnreauof TnveEUgatiou(FBI) . LdónlityHistory,SImiUaTy Check, 4vai]ableat the link noted - above. Provide anofficial nodflcäffon of infàrmadon(Self Query) frpm ‘ the NationalPractitioner Path Bait Pleaserefer to the NPDB websilefor additional information, Whehyou receive the

• a P “ReponsS to iout Self Query,”you willneed to uploadit toyour . ‘. unlineapplication.The report will ffeedto be uploaded, where

‘ prompted,in order to submit your apj,jicadoxu

, Cornplek Section 1 of the VerificationofPcrfimionistducaflon Eduafion formandforward to your’schto! for completionbfSecffon 2.The Verification programmust return the completed verificationdirectly to the . boar& .

2/3 ionimotq

. CheckList Name ksfrnädoni if

! ‘ContactLh6ABCPor other Nationally-recognizedcertifying. agenby andrequest an official vc4flcadon that you . are eligible . . .. and have appliedto sit for the cerifficaffon cxaminaffon to be sent Rxam Ehgibthty irect1y to the Board: This is.only required ii you axeapplying for . a tçmponry Graduate Perfusionist or Temporaryprovisional ______peth4Mopistlicense.

. Contact the licensingauthorities of the stateá,fethtories or •. cou$ries whereyou hold or baveever held a license, certificate, . permit registrationor other author ationto racflce. health relatedpro&ssion (whether active, inactive, expired or current) 1. d and request letters of goad standing/verificationof licensure in “°‘ - ‘ ‘ liat state orjurisdiction, The letter must include the following:

license issue an4 expirationdate, license status (current ot . expfre4)and disciplinaaystanding The letter(s) of good ;______standing must be salt directly to the Board. Youwili.ncedto upload, when prompted,próofofprofessional • Liabilityinsurancecoverage through self-Insurance,personally

•, ürchased ilsurance or insurance providedby your ethploS’erfor Malpractice the nhinimumamount of$ 1,000,000.00per occuntuce or claims .,Insurance tade. This proof of Insurance/certificate mustinclude your name and Audiate that you are covered under this . oUcy while performing perfusion services In the Commonwealth of

, .. . Pennsylvania. . - . . . Contactthe AmericanBoard of cardiovascular Perfi3sidn(ABCP) or othàr Nalionally-recoghizedcertif3dngagencyand arrange for CrifficaffonC your“aedenfial terificafipu” to be sent dfrecily to the Board. - • Plçase upload a uiurnvitaeiasnm listiig ff periods of

• employmentor ñemp1oyment (i.e., child rearing.research, etc.) ... . from graduatiàn from your highest level of educationto j,resent Resume/Curriculum (thc educationcompletedwhich qualifiesyou for this license):

Vitae . The list must be in chionolo&cal.order,includingthe name, city

. and state of the emploS’er,dates of employmentor advanced , -: ethicatibn/flining (inclU4ethe month and y)3 and description — of the practice activity. . .

an GENETIC COUNSELOR IO!3112019 Evaluation results: Board/Commission: OsteopathicMedicine License 7pe: OsteopathicGenetic Counselor Obtained By: Application

CheckList Name Instructions H If this appliáafioUis iot con1eted within sixmonths, updates of

. ceftain sections of the ppliqationand supporting.documentswin - be reqüiied. If applic4ble,backgrouizdcheck documents cannotbe

, older thn 90 daysfrom the date of issuance. If this applicationis

• 4pplicaff on pot completed within one year,you.will be required to complbtea 3ewapplication and resubmit the applicationfee. Youmay not

, netice in the Commonwealthof Pennsylvania until you have Deenissued a licenàe, certificate,regisftatiän, peimit, or auhorizaflon. [Anapplication fee of Sj59fJtis ° F required. Please note that all fees fr uon-refimdablé. i$Q. 00 Certification of

Supervisor . Mi health-related licensees/certificateholders and firneral

• directors are considered “manthtory reporters”under section 6311 of the Child Protective ServióesLaw (23 ES; 6311). Therefore, . all persons applying for issuanceof an initiallicense or certificate ‘ bm any of thehçalth-related boards (exceptthe State Boaid of VeterinaryMedicine) or from theState Boardof Funeral Directors . are required to compicte, as a coiithlionof licensuie, 3 hours of approved niniig by the Departmentof HumanServices (DHS). Child AbUse CE on the topic of child abuserecognition have anthtporting. A&r you completed the required cowse, theapproved provider will 1ecfronicaflysubmit your name1date of attendahce,etc. to the Bureau,For ihat ipason, it isimperative thatyou registet for the

. qourseusing the hilbzwadon pmvidedou your applicationfor licensute/ceidficafion. A list of DHS-appnwed child abuse educationproviders can be foundon the Dqattment of State Wcbsite.

In 1O/3112D19 raieckusst Name Thsfrncffons

. Provide a recent CrhhinalHistory Records Check (CHR from

• the state police or other state agency that Is the official repository for criminal history record infonnafioii for every

. state in which you have lived, worked, or completed professional tràininWstudiesSprthe past five (5)yam. The report(s) mustbe

. dated within 90 days of the date the application is submitted. For applicants living,working, or completing training/studiesin Pennsylvania,your cimc request will be automatically wbmiffedto the PennsylvaniaState Police upon submiisioh of this application. The PAXCHfee will be inflided at checkout

. YourPACHRC willbe sent directly o the BoaWCommission. Youwill be notifiedif additionalactign is required. For IMng, working, or completing training/studies outside Criminal History individuals of Pennsylvania duringthe past five (5)years, in lieu ofobtaining Check

. individualstate backgroundchecks, you may elect to provide BOTH a state CHRC fromthe,slate in which you currently reside, MW ydur FBI IdentityHistory Summary Check, available at ps://www.ibi.gov/strviceWcjiWidenthy-histozy-sunimary

• checks.

. Please note: Fçr applicantscurrently living, working, or completing training/studiesincalifomia, Axizona,or Ohio:Due to the laws of these Mites,the Board is not an eligible recipientof . CfU{C’soryourCflRCwillnotbeissuedtoyouforuploadtothe

• Board. Please obtain your Federal Bureau of Investigation (FBI)

• Identity History SnmmRryCheck, availableat the link noted . . ±ove. Piovide an offiCialnofificatiánof informaflon’(Self Query)from the National PractitionerData Bait Please refer to the NPDB

• website for.addiffonaiinformation.When youreceive the DatabankRtport ,, Response to yourSelf Query,’ you will need to up)oad it to your online application.The report will need tote uploaded,where pippipte4 in order to submityour application.

. PorwaMthe Verificationof Edudadon form to your ;thool/university tñ complete.Youare only required to vexi’ the level of edcaion completedwhich qualifiesyou for this license. Verification . The school must return tkeèómpleted verification form dfréctly to the Board. EduCatiOnal tRequest that your schoçl provide an official lxanscriptdiréeUyjo tanscripts kh pgriI

213 10131:2019 Checklist Name J Instructions Contact the ABGC or AMBG and request an official verification . . . ., of active candidate status be pentdirectly to the Board. This is only required if you are applying for a provisional genetic

. counselorlicense.

: Contaat the licensingiuthorifies of the states, tenitoriesor

‘ countrieswhere you hold or have ever held a license, certificate, . ,ermit, registraUoi or otier authorizationto practice a 4alth- relatedprofusion (whether‘active,inactive, expired or cunent) . f tandln a oos’ and request letters of good standmg/venficattonof licensure in ‘ that state’orjurisdiction. The letter thust include the following: license issue and expiration date, license gtatus(current or expired) and disciplinarystanding.The letter(s) of goad

. standing must he sent dfrecdy ft the Board. Youwill need to upload, where prompted, proof of professional Liabilityinsurancecoverage through elfinsurance, persénally purchasedinsurance or insuranceprovided by your employer for

. Malpractice the minimum amount of $1,000,000.00pe,rocctrrØnceor claims Iusunnce made.This proofof insurancefcertiflcate must include yOur name and indicate that you are covered under this policy while performing genetic counseling services in the Commonwealth of Pennsylvania.

. NiaionalCertificationfrom the AtheriàanBoard of Genetic afionaI Counseling (ABGC)or the AmericanBoard of Medical Genetics Certification (ABMG)’isrequired. Proof ofcerUf cationmust be ‘sentdirectly to the Pennsylvania Board.

. Pleaseupload a urriculum Vitae/ResumUHatingall periods of

• employmentor unemployment (i.e., child rearing, resçarch, etc.) from graduation from your highest level of educationto present Resume/Curriculum (the education completedwhich qualifiesyou for.this license). Vitae The list must be in chronologicalorder, includingthe liame, city. and state of the employer,,dates of employmentor advanced education/training(include the month andyear), anddesàripfion . of thepractice aàtivity.

ala iairnow - Evaluation results: Board/Commission: OsteojsathicMedicine License Type: OsteopathicGenetic Counselor Obtained By: Application iao & Name Tnstnidfions I Checktist : If this appliáafioñ is notcothpleted within.six months, updates of certainsections of the applicationand supporting.documents will

. ,e required. If applicQble,backgmund check 4ocuments cannotbe older than 90 days from the dateof issuance. If this applicationis 4pplicaflon not completed within one year,you will be required to completea

‘ new application and resulmit the application fee. Youmay not pracce in the CommonwealthofFenusylvania until you have been issued a licerthp,certificate,registration, permit or auhorizaflon; [Anapplication fee of is reqáed. Plëaáe note that all fees AJ)J)IIcaii F *OD non-refimdable. 4j3Q.. 00 Certification of

upervIsor . . Allhealth-related licenseeWóertfflcateholders and fimeral

. directors are considered “man4at&3ireporters” under section 6311 of the Child Protective ServicesLaw (23 P.S. §6311). Therefore, allpersons applying for issuandeof an initial license or certificate frbm any of thetealth-related boards (except the State Boafrdof

. VeterinaryMedicine) or from the Slate Board of Funeral Directors ae required to complcte, as a condftionof licens-uie,3 hOursof approved.tminingby the Depwtmbntof Humpn Services (UHS) Child AbUSe CE - on the topic of child abuáerecogpifionand reporting.After you have completed the required course,the apröved provider will . electronicallysubmit your name,date of attendance, etc. to the Bureaii.For thaheason, it is imperativethat you register for the - courseusing the informáon provided on tour applicatiodfor

. licensurWcettificaffon.A list of 1)115-approvedchild abuse . educationprovidérs.can be foundon the Department oftate

. Website. - 40/31)2019 .. I

f Checklist Name. Instructions

. Providea recentCriminalHistory RecordsCheck(CHRC) from thestate pblicCor other stateagency that Is the official repository for criminal history record information forveiy state in which you have lived,worked, or completed pñfessionai

. àining/studiesSpr.thepast,ve(5)ypars. The report(s)mustbe datedwithin 90 days of the date the applicaflon’issubmitted.For

. ipplicants living, working, ot completing training/studieshi

. Pennsylvania,your CHRCrequestwillbe automatically submittedto the PennsylvaniaState Policeupon submissionof this application.The PATCHfcc will be included at checkout. YourPACHRC will be sentdirectly to the BoarWCommisioñ.

. Youwill benoftfied if additionalactiQuis required..For complcfin training/studies outside Criminal History individualsliving, working,or thepast 11* (5)years, in lieu obtaining Cheek of Pennsylvania during of . individualstate backgroundchecks, you may elect to provide BOTHa state CHRC fromthe state Id which you currentli reside,

, ANDyour FII Identity History SummaryCheck availableat hflps:llwww.Thf.gov/services/cjis/idn±tv-bistoiy-summaiy checks.

Pleasenote: For applicantscurently living,working, or completingtraining/studiesinCàlifomia, Arizona, or Ohio:Due tothilaws of these states,the Board is not an eligible recipientof

: CHIC’s or your CBRC willnot be issuedto you for uploadto the Board.Please obtain yourFederal Bureau of intestigation (FBi) .. IdentityHistory SimimaiyCheck, available at the link noted . Pñwidean officialnoffficafiànofinfoxmafion.(SelfQuenj) from

• the NationalPracfftione,Data Bent Pleaserefet to the NPDB websitèforaddffionalinformafioa Whenyou róceive the DatahankRe oft p “RespoUseto your Self Query,’!you.will need th upload it to your ,nline application. The jpoft will need o be uploaded, where ipmpte4 in order to submityew appioaion. FOrwardthe Verificationof Edudaffon foftn toyodr You are onlyteqUired Ednésfi abboolhmiversityto complete. to ve* the , level of e&jàatiot completedwhiph qualifiesyou this Verifica ion lot license. - Thischool must return thecoinplefrd verification form directly to the.Board. Educational jjRequcstthatyour schoolprovide an official transcript directly_to banscrIfl VthoRnnrrt ‘4 10131/2019 [“ThbeckListName_11 Instructions Contactthe ABOC àr AMBG and request an official verification

. . . .. ‘ of active candidate status be sent directly to Board. Exam Ehgththty the This is onlyiequired if you are applyingfor a provisional genetic

. counselorlicense. Contact’the licensing authoritiesof the states, territories or L countrieswhere you hold or have ever held a license, certificate, permit registratioz or other authorizationto practice a health relAtedprofession (‘vhetheractive, thactivç, expired Letter of Good or ctrrent) andrequest letters of good standing/verification Standin tr “es’ of licensure in g ‘ that state orj’uflsdicfion.The lettermust include the following: licenseissue and expiration date, license status (current or . expired)and disciplinary standing.The letter(s) of good .______standing must be seat directly to the Board.

. r0,ffl need to upload, whereprompted,proof of professional

- - liabilityinsurance coverage throughself-insurance,personally.

, purchasedinsuranceorinsumnce provided by.yoür employerfor’ Waipracilce the minimiflu amount of$1,000,000.OOper occurrence or claims Insurance made.This proof of insurance/certificate must include your name and indicate that you are covered under this policy .‘ while performing genetic counseling services in the

• Commonwealth of Pennsylvania. afional Certfflcadôn from the AmericanBoard of Genetic National Counseling(ABGC) or the AmericanBoard of Medical Genetics Certification (ABMG)is required. Proof of certiflcafionmust be sent directly .

tothe Pennsylvania Board.’ ‘ Pleaseupload a Curriculum Vitae/Resumeliktingall periods of employmentor unemployment(i,e., child rearing, research, etc.) fromgraduation from’your highestlevel of’educationto present Resume/Curriculum (theeducation completedwhich qualifies you for.this license).

Vitae - The list must be in chronologicalorder,including the name; city

‘ ai$ state of the employer,,datesof employmentor advanced education/training(include the month and year), and descriptioii

. ‘ of Se practice activity.

3/3 wiaiaolP Evaluation results: Board/Commission: OsteopathicMedicine license ¶pe: OsteopathicGenefit Counselor Obtained By: Application ZYu\,Iaoa’-j Checklist Name Instructions if this applicationis not completedwithin six months, updates of certainsections oftheappliqafion and supporting.documentswill be required. If applicable, background check documents cannot be alder than 90 days from the date of issuance.If this application is Application at completedwithin one year, you will be required to complete a aewapplicationand resubmit the applicationfee. You may not ,ractice in the Commonwealthof Pennsylvaniauntil you have ,een issued alicethe certificate,registration,permit, or authorization. [Auapplicationfee of $5OO13is required.Please note that all fees “I’p— licadonFee tarenon-refundable. $45. 30 Cerfificalion of Supervisor &llhealth-relatedlicensees/certificateholdersand funeral directors are considered “mandätrnyreporters”under section 6311 of the Child protective ServicesLaw (23 P.S. 6311).Therethre, aDpersons applying for issuance of an initiallicense or certificate frdm any of the health-related boards (exceptthe State Boaid of VeterinaryMedicine) or from the State Boardof Funeral Directors are reqpired to complete, as a condition of licensure,3 hours of approvedtraining by the Departmbnt of Human Services (OHS) on the topic of child abuse recognition and reporting.After you navecompletedthe required course, the approvedprovider will electronicallysubmit your name, date of attendance,etc. to the Bureau. For that reason, it is imperativethatyou register for the course using the infonnafion provided on your applicationfor licensure/certification.A list of DHS-approvedchild abuse educationproviders can be found on the Departmentof State Website.

In $013112019

Checklist Name J Instructions Providea recentCzindrnilHistory Ricords Check(CHRC from the statepolice or other state agency that is the official rçpository for criminal history record Information for every statein which you have lived, worked, & completed professional trâining/studies.fot he pastfive (5) years. The report(s)must be dated within 90 daysof the date the applicafionis submitted. For applicanis living, working,or completing training/studies in Pennsylvania,your CHRCrequest willbe autOmatically submittedto.the Pennsylvaniathate Police upon submissioh of thisapplication.The PMtH fee w111be incjudedat checkout. YourPA CBRC will be sent directly to the Board/Conimission. Youwill be notified if additionalaCtiQnis required. For individualsliving,working,or completing training/studiesoutside Criminal Histoiy ofPennsylvaniaduringthe past five (5) years, in lieu of obtaining individual state backgroundchecks,you may electto provide

• BOTH a state CIIRC %m the state in which yoUcurrently reside, AM) ydnrThI IdentityHistory SummnryCheck,available at bts ://www.fhLgov&ceskiisridenfity-histozyy checks.

• Pleasenote: For applicantscurrentlyliving,working,or completingfraining/shidiesinCñliforuia,Arizona,or Ohio: Due to the laws of these states,the Board is not an eligiblerecipientof CHRC’sor your CC will not be issued to you for uplàad to the Board.Please obtain yourFederal Bureau of In’’esfigafion(FBI) IdentityHistorySummaryCheclç availableat the linknoted . above. Piovide an offiàialnotificationof information(Seff Query)from the National PractitionerData Bank. Please refer to the NPDB for additionalinformation.,Whenyou Databank website receiveth& ortr “Responseto your Self QuciS’,”you will needto uploadit to your • online application. Thereportwill need tobe.uploaded, where nbmpted, in orderto submityour application. Forwardthe Verificationof EducationIbmi to your to complete.Youare only requiredto verilythe Ed fi söhoolhmiversity ‘ level of eduoafioncompletedwhich qualifiesyoufor this license. Verification The school must return the completed verificationform directly to the Board. Educational R.equestthat your schoolprovide an official transcriptdkecdLto flanscripis 4w flnnd

213 1W31t2019 CheckList Name f 11 Instructions Contact the ABGC or AMUG and request an official verification .. of active candidate statusbe sent directly to the Board. This is • Exam Eligibility .. . ‘.. only required if you are applying for a provisional genetic

. counselor license. Contact the licensing authoritiesof the stites, territories or

. counties where you hold or have ever held a license, certificate, peimit,registration or other authorizationto practice a health- related profession (whetheractiye, inactive, expired Letter of Good or curfent) and request letters of good standmgfvenficaton St ding a of licensure in o ‘ tat state orjurisdiction. The letter must include the following: license issue and exphaflon date, license statis (current or expired) and disciplinarystanding. The letter(s) of good

, standing must be sent directly to the Board. Youwill need to upload, where prompted, proof of professional

. liability insurance coveragethrough self-insurance,personally .. puráhased insuraflceor insuranceprovided by your thployer for L%’talpracdce the miiiimum arnount.of$1,000,000.00per occurrenceor claims [nsunace made. ThIs.proof of Insurance/certificate must Include yoUr name and Indicate that you are covered under this policy while performing genetic counseling services In the Commonwealth of Pennsylvania. 1aflona1Certiflcaffbnfrom the American Bäard of Genetic a&nal Counseling (ABGC) or the American Board of Medical Genetics Certification (ABMG) is required. Proof of certificationmust be sent directly to the Pennsylvania Board.

. Pleaseupload a urdcu1um VitaefResumelisting allperiods of employmeht-or.unernployment(i.e., child rearing,research,etc.)

. from graduation fromyour highest level of educationto present ResumefCurrièulum (the education completedwhich qualifies you for.this license). Vitae The list must be in chronologicalorder, includingthe name, city and state of the employ’er,.datesof employmentor advanced

• education/training (includethe month and year), and description

. of the practice activity.

-ia GENETIC COUNSELOR REACT WATION

I. ______— ______

• (09i2017) STATEBOARDOF OSTEOPAThIC MEPIOINE’ REACTIVATIONor STATUSCI1ANGEAPPLICATION - ALLIEDHEALTHPROFESSIONALS Lest First Send to: FullHone

STATE BOARDOF Address - OSThOPAYHIC MEDICINE

P.O.BOX2549 Mdrta - HARRISBURG,PA 17105-2649 SIO Zip

vnrn.dos.pa.povlost Mdmsa . or: .. .: 2501 NORThThIRDSTREET 1mm. . HARRISBURG,PA. 17110

I tlcw,ailo. I

-Fora namednge, thdlcàanewnamebelowand nuathan S Y.xli photooepyoft lgaTdocameMveHfyfngthe namechangeQs; marrIage •canificate.dvozcadecne legaldocunwillnuVng rebMrof a maidennn. cit.).

. :

•LICENSESEXPIREEVERYEVENNUMBEREDYEARREGARDLESSOF REINSTATEMENTDATE

REQUESTINGINACTIVESTATUS’

O I2URRSnLY ACTIWSAWS REQUES11NbINACTIVESTAtUS .

Ido notwishto pmcd.my professionInthe Càmmonweélthof Pennsfrenie end with to piece myUcenseonan Inactivestabs.’ I.undaratondthat treactyete mvtqnie. I wiDneed to meet the rithu*id educalIo recuUiments. ot1nrnoMssbfl& rcbMu Ineumrte. and meet anyre-mW: clinicalskTh assessment an maufrudWthe Board.

. Cçmpietepages 1 and 3 of theapplication. Returnyour‘Active’nil and walletlicenses. Nobe Isrequired

APPLICANTSMUSTCOMPLETEThE IOLLOWING • Endose a checlcor money order, In Wieeppwpdate mñuMjsted bElOW,made payable to the ‘Commonwdalthof .. Pennsyi’ank.’ Ifyouhave been pmcflckigInP.ennistvanIabeyondthe aip[raticndale, Includea latefee of$5 par month . crpnftofamocth. -• • .: FEESARE NOTREFUNDABLE,Ch.cknrmonatordar mud be In“USfirnds.’ flqk: A procesaingfee ol $20.00willbe chmgedfor any checkor monpyctdflr•retumedunpaidby yourbank,ragerdjossofthe Ieason fornon-payment Yourcanlled checkbyourrecelpt&payment. - . . • . :. z:tt .. sias,co SIQEoo • • Genetic Coueàlor .‘ . $j2 “Pea Includesaienawal tea + $%mEdiveffo fee .‘ • ‘PTANSt $ioa “Fee Includes$50 iehaW&feet $50 eactivaffonft ‘. Phy5IclanAsslstent $1O • . . . -. - . . REØmlwyThernplst •• $25 • .

2. Completethe Iaal questionnaire. . . - . .

3 • Ifdocumentiwill be submIttedIn the Board under a nam different4mm yoórpresent name, submit a copyof the legaL documentevldondng11wname ohzng&Ø.e.,maTre Ucanae,dIvorce deoma, eto.)

4. - CcmpðivedkatbnofPractlcelNm.Pmflefonp. -. . • . — . - Altath a currant Drkvlum Vlaa listingj periodsofemployrpentor unemploymentQ.e..chM mafln research,etc.) rem the ejipiration the license to present. The eat must be in order. 5. date bf ducqcbdóal lglUde the monffimif vw and indicatethe stelaftarttbitk, Wificli the gmblowneigoccurred.

1 ______

-(09fl017)

Provldan offiobinotificationoFinformation(Self Queiy) from the Ntionai PmcWcner Data Bank. Please refer to the 5. NPDBwabslte for additionalInformation. When you receive the Response to your Self Query,” forward the entire report dlrecVyto !hè Board Ofika.. Youilwuldmaksa cccv fervour records, - rE..r_.t&t,_.t —c.-— — --.‘-:- V7.!-;:.7V’ .,—...... ConUnung.Eduèa1on . f t.’. ?-..•_• - ... t . 4W...

. AU. WEALTH.1ELAThDLICENSEES: ActSi Of2014 requIresthat ilcensàescomNeleat least 2 hours of Boar.appmvad continuingeducationInthIn abuse recognitionand reportingrequirements. Detailscan be foundat ‘v.v4os.oa.aa’r Fore . listof Boani-approvedpitvidn, choose the ‘Act 31 Mandated ChildAbuse RopoderTraining”link. Veriticadonof comniatlen must be sent electronIcallyd!racW *oçnPin course provider. Please note thaI it maytake 7—10dave for.ths oroviderlosubmit the records-toVieBoardcjfica. -

FOR ATHLETICTRAINERSONLY: Inorder to maJate your license and be hi comptiance withthe Board’s continuing . educationreutrements, you wilineed to providea copy ofyourcurrent BOG Ificaftoil FOR GENETICCOUNSEIMRS.PERPUSTIONISTS,S RESPIRATORYThERAPISTS: in ordecto reactivate your license fi. and be in compliancewiththe Boards conlinuing education rejUirements. you willneed to provide proof of mEedngthe Board’sconffnütno educallon requIrements. Gon6pidng education requkumante can be found attv.dos.Da.cov!cst. FOR PHYSICIANASSISTANTSONLY; In ardor tarüctivata §our !censs and be Incompliance Withthe Boards ntkiuIng educationreqLjmmet, you wffl.needto providea copy of yourcurrenthtCPA certification. Oclold ConflmlnpEducation: Section 9.1(afl2) of ABC-MAPreqUiresthat all presaib!rs or dispensers, es defined in Section 3 of Mt-MAP, completeat least two hours of cohWng education hi pain management, the Identificationof eddidlon &h the practicesofprecoibing or dlsen*g of oplotds-esa po&m ofthe total on6nting educa*n required. Ia. The required confiñuhg education is part of the total required end must be taken from a Board-approved écñtinulng education provider. . .

‘The ArNevingBeliertern by MonitoringAflPrescriptionsProgramMt (ABC-MAP)(Act191 of2014. as amended) is syalieble on the Legisiatwe’swebsifeat Nti/tw.tegis.stMe.ta,us/cfdoW1.eoIsftUuconsCheckcftn7MI4ôe=HTM&w=2O14&sossinthO&smthLwind&act=

19i . i L°L ‘i — t_ -- - - t fl”X .4 i,tJVfl7J%i1.Tt,.kt 1.*Afl u! i-’b- -t’D3’. s’çt Aa.Aeupuncturlsts &Gontic Cpunsejen: Shall provideproofof pTofess[onaIIlabity kisurence coverage thm4u self Inawance, parsonai purchased. insurance or Insurance provided ‘by your amp!oyer for the minimum amount of $1,000,000.00 per occurrence or claims made. Thisproaf of lnsumncelcethflcate must include your name and IndicetA that you are covered under thIs policy white performing services governed by your license In the

Commonwealth of Pennsylvania. -

ifthisepØcetion is nMxmpletad within eli mentht updates of certain sections an&or sr4worthg docrmmentawi be rqulred.

EffectiveJan. 1, 2017. ad 181 of 2014 raqu!ms&i prescñbere and dispensers to registerforthe Penns lvaniaPreacrlplion Drug Moniio4ngProgram (PAPOMP).PrDscrflea ers required to query the PA PDMPSystem fa each patient the firsttimethe patient Is prenibed a con&olledaLtetenco bythe prescriber, when there is clinicalconcernthat lbs patientmay he ebustng or divertinga contzdledeubstenca(s), andkr ecth llme.thepatlentis prescribed an oploiddrug product ore benodlazeplne. To leero rme and to register, please visitwcm,doh.caoovMdmp,

2 .. - (02cm , LEGALQUESTIONS

THEFOLLOWINGLICENSEREACTWA11ONQUESTIONSMUSTBE ANSWERS). Ifyou answer YES’ to #2 through WlZ p&4e complete detailsone separate sheet as wellès copies of mievapt documents. Slim and dab below.

.. . Yea. Nb Doyouhold or have youever held a Ucehee,codificet, permit,registrationor Otherauthcflzauonto pmctica any heaflhcelslad professionInany slats orjurtsdlcticn? Ifyou answered yos, provide the profession and 1. statáorjurtadlotloa -

•‘ Have you withdrawnan eppkaon for .a pmksslonai a occupabonal Ikerie, cerdfien, permit or a reglantlon, had an eppthaUn denied or mftsàd, or for bdprmarymssons agreed not to apply orreapply . faa profes&vn&ororcupaonal IicenOe.cestl1kaio-pesmltøástglsbatienInany state orJtntsdlon? - Have you had disØlinary action taken against’a prUfesabnWor cc upationallicense, certificate,permit, 3. reglafrabonor oDin?authorizationto practice a prOfeulOn or occupation Maiiedto you In any slate & .jurisdlcbon or hew you agreed to voluntary swmndar jii !teu of dlsdpllne? Doyou wãenUy have any dI&clplinorythemes pending against yourpmfoslonpI or occupationalkense certificate,parrnftor registrationInar, state orJudsdk*n? . Have aj been nonvioted(found guilty, 1ed guilty a pied rntocon%tidem) mtved prttaton without ,- venilcior accalorated r*abititatlve disposition (AcID),as tóany criminalcharges, felonyor misdemeanor, ART)or ‘ thchsdingany’drug lawvi&etions? Note:Youare not re4ulreilo disclose any othOralmhal maNor that has been expaiged bycider ofa jjj .

6. Cc youwrtentiy have anyci1mhaIcharges peliding end unresolvedhi anystate or Jurisdiction?

Haveyou ever bed practicepdvflageadenied, revoked, suspended,or reaUict&lby a hospitalor anyheaith . camfacilty? ., 8. Hive youhad yaw DEAmgtreilon denied, invoked Orrestricted? Hva you had pioviderprMiges denied, osd,auspandad matridedhy a MedicalAssistance agency, • - Med Ere,lhhd p&typayororsnothçrauthodty? . Have you been disged by a hospital. university; or msaarchieclKty Wth ‘Adatinflseardi pmtàccts, o faisfrng research, orenpagimpInother research thlscanduct? - Hake you engaged in the Intemperalaor hbitiaI ce or abuse of alcohol or narcotics, halluolnogarilosor

. -. • ‘ other dwgi orsubstances that may impairjudgment or coordTheflon? Since MayID,20P2-,Imvuyou been the subjedof a clvi malpidica lawsuit? if yea, pkaae submit a copy of Ua entire CMI Ccmpblnt which muse Include the filno data and the data we war. send. Submit a a statement whIch Ináiudes complete details of the cemplabita that have been filed against you. 11you previously reported the complaint(s) to the Board provide thedocket nimibelte)!

. VEHWICA119Nor INFORMATION--

of StaLeand has not been aReradorotherwise rrcdlftedInany I ,erI&that this appacesoni Inthe-origInalformatas supplied by the Department wy. lam awareofthe crimbiNpenaltiesfor tamperingwithpubic records or itnnatii urthr 18 Ps. C.S. 4811; I thatihe statarnentaIn tie applicationwe bue and conücttothe bqt ofmy knowledge,kilwmationand beiW. Iundereffindthailalsastawmentsem madesuNseti the penates of lB Pa ca 4aM (mbfirgtowwwornfelalflátbn to autbodliss)andmayresultin the suspension,ravocelon,ordertal ofmyricebsa, cwbUcete,penn?’xmglftation.

— Last . At. - ama FdlNsme

- - - ..- Social 8.cürlty# . --

NanteOf - .- Univenityor - VaOIG,adusuarr SdwoI ‘- . . r. . jMandator) -

3 SigiwiuTa permit of em applltaticnsm I vaifty 2. I8 e.vare Pa or that Rave Pennsylvania lapsed Have itgltbttion. as. Of at this Ucensee the § tue you you appUon or 4904 cdiThñai since end engaged been eIsUn license cogmdto you paneltisa bin Yow employed placed hi to the or VERIFICATION the unaworn or càrtificaUon oitgtnai for beal practiced reactivation it

a Iamadn by on of faislficaflon fomn th&tve my the knaMe4e, lapsed In feddral as Wth your status? supplied cannot lb flu: crsinëe authorities) profession onmment bifomia&n OF acorde by be the you PRACTICE pmcOsed D nd placadit or in and flioMalSWla 4 In may Infwmatbn PwinsfranJa beflat the meuft on prectco unless I inactive undwtlaM in under Via I and (moo NON-PRACTICE. duspanslcn. this of 18 status? has that Pa. your yOUT page not false G.E. bean profession Ikense revoaction, C Is statements !ltared 4911. completed Date or .1 or or since cenificaUon verify an othomise dental made “ that .tur of mzbjebfl my the modified lliise, statements In any certificate, penaitas (l7) way. In Ibis I I ______

Ju\ L MO%L (0912017) STATEBOARDOF OSTEOPATHIc MEDICINE REACTIVATION or STATUS CHANGE APPUCATICN -AWED HEAUH PROFESSIONALS I ]‘tièf - nrt j fruvName --

STATE-BOARDOF Mdmas . - OSTEOPATHIC MEDICINE p.o. aox 2M9 Addrns HARRISBURG,PA 17105-2549 Cay . Sn’ Zip www.dos.pa.govlost tt I - or 2601 NORTHTHiRDSTREET Email: HARRISBURG.PA: 17110 j UcaneeNo. ToMflonaNo. - I.j.,m’: . I — Fora name&ano bd2ale nan ‘n below aid éliath an a 34x 11 pholoxpy of a legaldormônl yedln; me name ctiarie (to. man1ee dNwcedectoa NgeldowsñentthdlcaangretakLlgnra maidenriwne,ate,).

NawName:

LICENSESEXPIREEVERYEVENNUMBERED YEAR REGARDLESS OF REINSTATEMENT DATE

REQUESTING INACT&ESTAWS: o URRENTLYAC1NESTATUSREQUESTiNGINACTIVESTATUS

I do nOtwish b practIcemy proFession in the Commonwealthof PannsyWanlaand wrab to place my license an an lnactlvestaws I undrnnnd that to-reslvate my license. I wiNneed to meat the nffinfl edursffop renuhwfl. obtain rofessjonal ilablitv 1aoid meet any re-entry. c5n?caickiHsassescinent as requIred bqthe Boatd. • -CompretapagasI end 3 of the application. Return your ActivC wall and walletlicenses. • Nofee is required APPLICANTS MUST COMPLETE ThE FOLLOWING: zz-1 Enclose a cfleck or money order, In the approprIate arjunt listed below, made payable to the tommonwealth of Ponns)lvñla. Ifyou have been praotidng In Pennsylvania beyond the eçlraUon data, Includea late fee of 55 per month . orpartofa month. -

EEEAR NOTREFUNDABLE. Check or money order must be In MU$funde. A rwocessbigfee of 520,00 wI be chaiad for any thedccrmcnay order returned unpaid by tw bank regerdleseof the: mason fornori-psynianL Yourcancelled ctistklsyourrec&ptorpayment . 1. : $jS5. Q0 a GeneticCounselor . $$S “Pee Indudee 6’mnewal fee 4)adreacdvavon tea • perkiejonlat $100 “Pee InclUdös$60 renewalfee + $50 reedtK2tlDnfee.

. Riysian Azslatdnt $1D - - . ResptratoiyThemplst $25 -

Z Qompletothe gal questionnaire. - If doajpentawiN be submItted ft the Bcd tinder a name dflferentfrom yew presar name, submit a cepy of the legal • documeri e’Adenclngthe name change (La, marriage nears., divorce decrde,et).

4. Completethe Verificationof Pmce I Non.Prnciks form. . . dilid Mache current CurdculumVitae lIsilngall periods of employment or unemployment (l.aL rearing, macarch, etj from - — ardor, Include s the nplraton date of the llceae to present. The list ñnst be In cJwoqioioalcal the mouth fld year. and • Indicate the sflftrtorv Inwhich the omolc,1ne, erairmd. . . (09.2017)

Provideen OfficIalnotificationof Information(Self Query)1mmthe NationalPçachflonarData Sank. Please refer to the Query,w NPOBweb&tefor additionalinfonnadon. When you receive the Raspiso to your Self forward the entire report dIrectlyto the Board Offia Youshould make a coov-forvourrecords.

.‘•. .— ‘——.. — p’;-)-r1, —. f.,2f .-,!.‘., .; • .. . ..; - :::.: r ,--.• .*€t’1d-!a1 HEALTH-RELATEDLICENSEES: Mt 31 of 2014-requIresthat Ecenseascomplete atIeäst 2 hates of Boerd-appro’ad continuingeducation In ChNdabuse recognition-end reportingrequIrements tstalls can be found at svww.dos.oa.aov Far a lid of Board-approvedproviders,choose the AcI31 MandatedChildAbuse ReporterTraining”link. Verificationof nleUon mist be card e$ettmnlcallydiredi fromthe course ymldet. P’ease hole that ItmsQ 7-ID dew br the Drouidet sebmit the mrds to tho3ard office.

FORATHL.FT)CTRAINERSONLY: In onef to reactivateyour llcenie and be Incompliance vith the Board’s conllrnIng educalon requirements,ycuwilineed to providea copyol yourcwrent BOGcertification.

FORGENEj1CCOUNSELORS,PERFUSTIONISIS,&RESPIRATORYTHERAPISTS: inerder to reactIvateyour lidanse 9 end be In compliance withtho Boards continuing education requIrements, 9011willneed to provideproof of meeting th& Ecard’s continuingeduce on requirements. Continuingeducation mqLAmmentscan be found at www.dos.oa.pov/ost,

FOR PHYSTCIANASSISTANTSONLY: in order to reactivate your Kccnse end be hicompliance withthe Boetd continuingeducation requirements, — willneed to provide n copy of your current NCCPAcertlficaiion. Oioid Conlinufrth.Educatlpn:Section S.1(o)(2) of ABC-MAP”requires that all prasathert ordispansers, as defined In Section 3 of ABC-MAP,èomplele at least two hours of continuing education In pain management, the Identification of eddiction orin the practices of prescribing or dispensing ofaplolds as a portionofthe total continuingeducation required. o, The required continuing educaHonis pert of fluetotal required and must be taken from a Bcard,appmvad continuing educationprovider.

ThaMhlovingBetterCare byMonitoringAllPrescriptionsPmgmm Act (ABC-MA?)(ActIDI of 2014, as amended) 1 availableon the LeglstaWm’ewebslte at . -

ii* - - pit All baj1%?pj ‘ic ftqj%1be4lL -. r ,ji5 \i’/Qjn zZsivjt,1 is ntJ tu .— -‘ Ji,,1cS1r’J72EI&6,t - - ,,- - .-•t.- - - L;fl*ct,.sL NJ- Acunwnctwfsft p Genotlo pothnaipn: Shaflprovideproofof professional liabilityInsurance coverage through sell ii, insuraira, personally purchased Wistnunce or InsureiWe provided by your employer for the. mSimum amount of $1,000.000.OOper ocourren orclaims mede. This proof of insumncdcertlflcate must include your name and, indicate the! you aro.càvered under thie policy while perfoflfline services go%wmedby your license In the Commonwealth of Pennsylvania. —

IIthis appicailon la notcompletedwithin nIxmonths, udatas of certainsections andior supporting documentswillbe required.

EffectiveJam 1, 2011, act Wi of 2014 requires eli prnacthn arwiWspensers to register for the Pennsyienia Prescription 0mg MonitoringP:ogram (PAPDMP).Pmscsibersare requlod to qkierythe PAPOW System foreach patientthe mtt time the patient Ispresarted a controlledsubstance by the prescriber. wtuenthere Is diital concern that the patientmaybe abusIngor divedln a conboltedEubtence(s), endloreath limethe patient Is prosatbed an oplolddn product aTe benzodlazepine.To learn mote end to regsler, please visitvjw4oh,oa.qovJpdmp,

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Have In orpmetked in your in Penns)dvanIa&nce Ucense or 1. you engeiad prolesslen yaw cØflcaUon lapsed orsince yuu placedlion Inactve steWs?

flavB yas been employed by the federal government In the prnciloe of )tIIT pmfssslon since your 2. Pennsylvaniar,censca ccdWeaffcxilapsed sin you placed iton maclivestatus?

Iveit4’ thai this app&ton is frithe Mgkid formalas applied by the DepertmentofState sr4 has not been a’Iamdoratheqwfao ma9aJ hany way. I am ewam of the ettm& panfli W flñ,g wflh uWc ma a k*mwtan under iS Pa, 0.5. 4811. I verifytat the eflfl hi INs appuosifonem Ine and camct b ths bestalmy k2n4edgu, thfonnatjcaand heist Itidnand thotfWaeslalemante are made subject late penawes of 15 Pa 0,6, 4804 (r&atn in unsstm f&Wicalan in siCodVes) eM may msu In tie suspension, mncm or denial of my Esnas, certfe, priM or .fllm&n.

5Iitn & Ursa. Date

4 (nfi7)

STAE BOARDOFOSTEOPATHICMEDICINE-. REACTIVATIONor STATUSCHANGEAPPLICATION.- ALLIEDHEALTHPROFESSIONALS : La flat Send to: FunName .

STATEBOARD6F -a . OSTEOPATHICMEDICINE P.O.Box 2549 Md’s HARRISBURG,PA 17105-2549 city -- sin www.dos.pa.govfnst Mdrna . . - or 2601 NORTHTHIRDSTREET HARRISBURG,PA 17110 i:I.J . N:

Fora name cJ’azige,Indirat.newparsebeb,#and atiach en 8 34x 11 photopopyof a ieaai dosiment vsrtMng the name change 0*. mardö ceiulite. dIvorcedariee,laØJdomimentIndlcfln mno ofa maiden name,e

NowName: — . .!- -

LICENSESEXPRE EVERYEVENNUMBEREDYEARREqARDLESSOF REJNSTATEMENTDAW

REQUESTINGINAcTIVESTATUS;

0, CURRENTLYACTIVESTATUSREQUESTINGINACTIVESTATUS

1do not wish to pmdllca my profesIop Inthe Cónimonwealth of.Pennsylvaniaaridwishto piece mylicense on an Inactiveatatua I uñdemtend the?to reect&’stenw license, (WI! need to mAst the co,gjnu& education rrniufrmtenw. obWn bmsslonal Ueb4lity Inewence.end meet anyre-entry ctircib ñsssmanI mauir,d by the Board. • Complete pegs I and 3ct the application. • Return your Aetive’walland walletlicenses. • Nofee Csrequired -

APPLICANTSMUSTCOMPLETETHEFOLLOWING:

Endose a thudc or njuiey order, in Urn oppopdatb amountliMed below, made payable to the Ycommorrwedji of Pa,nsylvenW Ifyou have been ptacffc In PennsvanIa ba3vnd the eçkaton date, hic1udea tete fee ur-$5per month opartofanio,t . . . -

FEESARE NOTREFUNDABLE. Check or money Order must be lit “UShinds? f: Apocesaing fee of 5fl00 witbe chargedfor any oteck or moneyorderreMiied unpaid byyour bank, reeMIoes oltho rsaaon fornon-payment Yourranceiled yturtofpaymt . — 1. Acupuncturist : 4a$$00 -svo°°. SID.S.bO Ganefic Counselor 3)25’ Fce InokidesVEinBWaI fee + $eø’reaotlvauonfee. • rfuslonlsl $100 “Fee includes $50 rene’al fee + $50 mact1vaon fee. • PhyslclanAssIstant $10

• • Rosp[rtoryflêmptst $25 2. CwnJete thu legal quesOonn&re. —______

Ifdocuments wi be submittedto the Beard. under a name dIffaiDnifrom your present twin, mbmfl a copy of the legal ‘ dacumentev4encfogthe name change (l.a. manlage license, divorcedeaae, at).

A. Complete the VerifIcationof PracticeI Non-PractIce knit . . ., — Mach a current Cuñtuhzn tae listingfl periods of employmentor unemployment(Ia., ditd mariog, teieayrj, at) horn the wqIratlon date of th license to preseni. The lIst mw* be In dimnoloolcal ordit WIdA the morriliwadwe,. end Indicatethe stateftnriftoryInwtldi the employfnentDowned. ______

(O12017)

Providean officialnotificationof lnhjmatlon (Self Query fromthrNallonal PmclBlcnerData Bank. Piaase tefer to the B. NPDBwebsite.1ccaddItionalinformatIon. When you receive the Response to your Self QuerY,”foiwaid (hi entire .itport directly to the Botrd office. Youshould make a copyfomvur cords. •, ,. . .‘ • • ‘ C’o1it1hüiflQ.Edütodób ..: .. .,. . .._i . Z.rt’. L HEALTh.REATW UCENSflS: Ad 31 of 2014 requIresthat licensees Cctnpiete’atleast 2 hon of Board..approved hi child reçognWonend reportingreqttements. Detailscan be foUfldat vA’.w.dos.pa.oy Fore citnuIng education ise dfl( 7. lIstof Board-approvedmviders, choose ( MandatedChildAbuse RepaderJmJnln fink. VerificationcfccntUon sent electonloallydirectlyfromthe course proAder. Please note that It maylake 7-iD dëvs forthe oroyldorto submit the recoids to the owtl office.

ONLY: order to reactivate yourlicense and be In mpliance with the Board’sconllnulng FORATHLETICThMNE ! edUcaflonrequirements,you willneed to provIdea copy of yow currentBOCcertification. ORGWIETICCOUt4SE[ORS.PERFUS110NISTS.a RESPIRATORYTHERAPISTS: hoMer Joreactivateyourlicense D. art be hi compnce 41h me Board’s conunumg educationrequirements, you wtl need to provide proofof meaUngThe Board’soonI1mngeducatiobraqu*emenb, Continuingeducationreqtimmen can be found at tw.w.dos.De.cov!osL FORPHYSICIANitssT$TAR S QNLY: Inorder to reactivateyourlicense and be Incompliancewith the Board’s

. ccntJnungeducation requirements,you willneed to proi4dea copy or yourcurrentNCCPAcertification. OploWContinuingEthicaticn: Section 9.1(a)(2) of ABC-MAPinquIres Thatall pmescrthersor dIspensers, as definedIn SectIon 3 of ABC-MAP,complete at least two hoür of continuingeducation In pain management, the identificationof

. addictionor Inthe practices ofpresulbfng or dlspensfn ofoploidsas a portionof the total continuingeducationrequired. o. .me required continuingeducation is part of the total required and must be taken from a Board-apprcod continuing educationprovider, .

9’he AchievingSetter Care byMonitoringAl PrescriptionsProgramAct(ABC-MA?)(ACt191ci 2014, as amended)$e avebble on the LegIslature’swebsila a .______121. • . .ry.wtc.fI I.-’y--:-”” rr •.f4 c 0 •‘ T “ •t r •Afl1Ft-i/ ‘T”Ifr t’t ‘ ‘itzkjt&ns,? £a$M C1•’ 4aLR ALLAtupunctcirbts & Genetic CounselorE Shall provIdeproofotpitfesshnal IlebliltyInsurance coverega throughself j. Ipsurenca, personally purchased Insurance or Insurance pmided by your employer for the mininum amount of $1,000,000,00per occurrence or claims made. This proof of Insurancelcertlflcate must include your name and indicate that you are covered under this policy while peflomilng services governed ly your lIcense in the Commonwealth of Pennsylvania,

ifthis applcallonIs nrAcompletedwithin six months. updalas of ceijeinsections ar)WorsuppOflffigdocuments willbe required.

EffectIveJan. 1, 2017, aCt191 of 2014 requires all prescflhers and dispensers to register forthe PennsylvaniaPrascrtptjonDrig MonitoringProgram (PAPOMP).Práaers era tequired to querythe PAPDMPSystem for each patient the lrst timethe patient Is prescribed a controlledsubstance bythe pmccdber. ½4ienthem is cute] concern that the patent maybe abusingordivertinga controlledsubstance(s), .rd!or öadi timame pollen!Is pmscnbed en opiolddrug productore b!nzodlazeplno. To learnrcomand to mgister please visitwew.doh,pa.qovFpdnw.

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• VERIFICATIONOF PRACTICE!NON-PRACTICE “ Your macflvatlon cannot be processed unless this page Is completed — I Phi Full Name

license ND.

pmctf in your h’cense or 1. Haveyou engeed friar ted in your profession PennsWvanietince cerliflcaUon lapsedor since you placedIton lnaive stabSs?

• Have you been employed by Mis fedørai govesnmeMIn the practice of your prdessli since your Pennsylvania license or codification lapsed or since you piaced It on inactive status?

Ivedfy Thai(his sppcaUon is hi the odginairocvat as suKtJed by the Depatneni cStts md herant ba& altered or tthrnwfss madffladIn anyway. I em awwe of the cilminal ponaides let Wmpndfl9with putno moords or infraUon under 15 Pa. CS, § 4911. I ndty that the st&cnien In This epØosuon are two and cen.d lathe besIdnyimowiedne. Fnfothiadceand telrf. Lundelstand that false otamonts are made subject to di. ponoltes silO Pa CS. § 49&4.freledhgto unawom 1slflcsUon bAulttddas) aid nay iliult Inthe suspension, revocadon,ordentol of my Icenso, corlificato, ponWior rsgbbstlon, . . • —

Slgnahn ofUce,eo on

4 GENETIC COUNSELOR tEMr0RARY PROVISIONAL IWIWdIB Evaluation results: BoardfCommicsion:OsteopathicMeWcin% License ¶e: OseopathidGeneticCounselor.4 T€rYi( Rb\t00 oL’ Obtained By: Application G&t- Q,ouna 9OcQO

CheckLiatName fl ñsfructlons if this appliàafibnis not completedwithiuØxmonths,updatesof óèrtainsectionsof the appliqationend supporting,documentswill berequired,if applicable,backgroundcheckdocumentscannotbe olderthan 90 daysfromthe dateof issuance.if this applicationis Applicafion riotcompletedwithin oneyear, you.wfflbe required to completea aewapplicationandrcsumit theapplicationfee. Youmaynot practicein the Commonwealthof Pennsylvaniaunifi youhavo becifissued a license; certificate,registration, pemñt, or aiithnrbzaNnn fl rn it Mfl tiAl.L4ALW — tnt’ -tull LQSP3.’r An applicationfee of $5Q) isrequired.”Pleasenote thatall fees 4pphcadon Fee arenon-refimdab1e.’j ‘ rcernfifioflof An o4 470.00 a tete -r at;.a T Supenisor iln\p 1Thvvciconc&SPckc Co.flsa1J

,, Allhealth-related licenseês/cerlificate’holdem’andfuneral . directorsare considered “manItoxy reporters” under secfion6311 ofthe Child Protective ServicesLaw (23 P.5; *6311). Therehe, . allpersons applying forissqanceofan initiallicenseor certificate ‘- fromany ofthe health-relatedboards (exceptthe StateBoth-clof . areVeterinaryMedicine) or from the State Boatd of Funeril Directors required to complete, as a conditionc1licezsux-e,3 hours of

‘ approvedtainhg by the Departmbntof HumnnServices(PHS) Child AbUSC CE on the topic of child abuse recognitionand reporting. After you

• havecompletedthe required course,the approvedj*ovider will electronicallysubmit your name,dateofaftendance, etc. to the ‘ Bureau.Fot that ieaon, it is imperativethat you registerfor the . ourse using the information provided‘onyourapplicationfor

- censwWceiffflcadon. A list of OHS-approvedchild abuse

. . educationprOviderscan be foundon the Depastmentof State

. Website. -

ira 1O!3W019 Instrutfions _CheckList Name_fi II

• Providea recent CriminalHistory Records Check (CHRC) from

• thestate police or other state agency that Is the official repositoryfor criminal history record Informadon for every state in which you have lived,worked, or completed pmfessional

. triining!stUdiesior the past five (5) years.The report(s) mustbe dated within 90 days of the date the application is submitted. For : applicantsliving, working,or completingtraining/studies in Pennsylvania,your CHAt request willbe automatically submittedto the PennsylvaniaState Police upon submissioiiof be Yourthisapplication. The PA3tH feewill included at checkot PAOHRC will be sent directlyto the Board/Commission. Youwill be notified if additionalaCtiQn is required. For criminal individualslMng, *orking, or completingtraining/studies outside to ¶3’ Pennsylvazñ duringthe past five (5) years, in lieu of obffifnfng Check of . individualstate backgroundchecks,you may elect to provide BOTHa state CHRC fromthe state in which you currentlyreside,

. ANDydur FBI Identity History SummaryCheck, availableat

. bs://www.fbLgov/sen’ices/cjis/identity-history-summary_ checks.

Pleasenote: For applicantscurrently living, working, or . corhpletingfrainfrig/studiesinCálifomia, Arizona, or Ohio:Dii to thc laws of these states,the Board is not an eligible recipientof

- CHRC’sor your CNRC will not be issued to you for uploadto the Board.Please obtain yourFederal Bureau of Intesfigation (FBI)

. IdentityHistory SummaryCheck, availai,leattire link noted ibove, . Piovide an.offlélal notificationof information(SeWQuay) from thewthsiteNational Practitioner Data Bat Pie se refer to the NPDB for.adthfionaIinformatioi. When you receive the Databank Report “RespoUseto your Self Query,”you will ed to upload ft to your onlineapplication. The report will need tobe uploaded, where

. zompttd, in order to submityour application. Forwardthe Verificationof Educationform to your

.. bhooYimiversityto complete.Youare only requiredto verifythe level of education completedwhiph qualifiesyou for this license.

• e r’ . The school must return thecompleted vedficaffon form

, directly to the Board. Educational Requestthat youi schoçl providea officialtranscript dlredffyjo Thamcdpft thu nnnra 1013112019

Checklist Name . Instnidfions Il I ContacttheABGCorAMBGandr quesian official veflflcatio& . . of active candidatestatusbe sent directly to the Exam Ebgzbthty.. Board. This is only required if you are applying for a provisional genetic

. counselorlicense.

. Contact the licensingautharities of the states, tenitories or countrieswhere youhold or have ever held a license, certificate, . permit,regisfratibRor other authorizationto practice a health- relatedprofession (whether inactive, Letter f Good active, expired or current) andrequest lettersof good standing/verificationof licensure in Stan ding a OGS’ ‘ that state orjurisdicffon. The letter must ftclude the following: license issue and expirationdate,license status (current or expired) and disciplinarystanding. The letter(s) of good standing must besent directly to the Board. Youwill need to upload, where prompted, proof of professional

• liability insurance coverage through seli4nsurance, personally purchased insurance or insuranceprovided by your employer for Malpractice the minimum amountof $l,000,000.ODper occunence oEclaims Insurance made.This proof of insurance/certificate must include your . name and Indicate that you are covered under this policy whileperforming genetic counseling services In the

Commonwealth of Pennsylvania. -

. NIaffonaiCertification from the AmericanBoard of Genetic National Counseling (ABOC)& the AmericanBoard of Medical Genetics CettlflcaflOn (ABMG) is required.Proof of àerflficafionmust be sent directly to the Pennsylvania Board. -. Pleaseupload a çurfiàulum Vitae/Resumelisting all periods of• employment or unemployment (i.e., child rearing, research, etc.) from graduation from your highest level of educationto present

. Resume/Curriculum (the education completedwhich qualifiesyou for this license). Vitae The list must be in chronologicalorder, includingthe iiamé, city . and state of the employer,.datesof employmentor advanced education/training(include the month and year), and desäriptidn of the practice activity.

3,3 1o,31nw Evaluation results: Board/Commission: Osteopathic Medicie License flpe: OsteopathicGenetic cpunselor41m. Acor)q ObtainedBy:Application Qrçj{cCoi.rs4or I aoa Name Instructions s I f_CheckList If this appliáaUoñis not completedwithin six months, updates of certain sections of the appliqadoñand suppbrthg.docnents will 1bereqUired.if applicflle hackwouüd check documents cannothe ; older than 90 days from the date of issuance. TIthis application is Application lot completed witithi one year,you.wil be required to completea new application and resubmit the application fee. You may not ?mchce in the Commonwealthof Pennsylvania until you have

. been issued a lic&e, certificate,registration, permit, of authorization. or . An application Application Fee fee of $$fr® is requiretPlease note that a]]fees arenon-refimdable.., •%$j’30.00 Certlflcadonof (¼ oc4’ S 4iflrs çre.-c,r . Supervisor okacaWc ‘°wfravct’cn Genkc.Ccuns)or l&elc ., Allhealth-related licensees/certificateholders and flmenl directors are considered “mandiltozyrepflrs” under seàfion6311

. ofthe Child Protective ServicesLaw (23 P.S. f 6311). Thereibre, allpersons applying for issuance of an initial license or certificate frbrnany of thehealth-related boards (except the State Boaid of

. VeterinaryMedicine) or from the Stat Board of Funeral Directors . arerequired to complete, as a conditionof Ucenmthe,3 horns of approvedtraining by the Departmentof Human Services (fS) C AbUSC the topic of child abuse recognitionand reporting. Alter you havecompleted the required course,the appthved provider will electronically submit your name, date of attendance,etc. to the Bureau.For thafteason, it is imperativethat you register lot the course using the informAtionpmvided on your applicationfig iicensure/c&tificafioa A list of DES-approved child abuie education providers can be foundan the Departmentof Sate -. Website;

In lDfllflOlS

CheckList Name . ksfrucdons [Providea fecent Cthiinal History Records Check (CHRO)from .. 1thestate police or other flteagency that Is the official repositoiy for criminal history record Information forevery state in which you .hve lived,worked, or completed piofessional

.• trining/studies.forthe past.five (5)yars. The report(s)mustbe datedwithin 90 days of the date the applicationis submittEd.For applicantsliving, working or completingtraining/studiesin Pennsylvania;your cimcrequest will be automatically submittedto the Pennsylvania ffite Police upon submissionof this applicaffon. The PATCHfee willbeinc!uded at checkout, YourPA CHRC will be sent.dfrecflyto the Board/Commission. Youwill be notified if additionalaCffQnis required. For .___ ,.,,. individpalsliving, working,or completingtraining/studiesoutside of Pennsylvania during thepast five (5)years, in lieu of obtaining individualstate baekgwund checks, you may elect to provide

• BOTHa state CHRC fromthe state in which you currentlyreside, kND your Nfl Identity Ilistoty SummaryChcclç availableat hilps:llwww.fbi,gov/sewices/cjis/idenflty-history-summarv

. . checkd.

Please note: For applicantscurrently living, working, or

• - coihpledng fraining/studiesinCáljfornia,Añzona, or Ohio:Due to the laws of these states,the Board is not an eligiblerecipientof . CHRC’sor your CIWC will not be issued to you for uploadto the Board..PleaEeobtain yourFederal Bureau of Intestigation (FBI) . kientilyHistory SummaryCheck availableat the link noted above. Pñwide an offi6ialnofificafiàn of iñformation:(SelfQuery)from the National Practitioner Data Bait Pleaserefer to the NPDB

- foraddifional Databank Report websit information.Whenyou receive the ‘spoze to your SeWQuej! you will ned td uploadit to your online application. Thereport will need tobe uploaded,where piompted,in order to submityour application.

‘ . Forward the Verificationof Eludatioñ ibnn toyota. söhoolhmiversityto complete.You are only Ed if required toverily the level of ed4OaUoncompletedwhich qualifiesyou for this license. VC• ça The school must return fhe-cothpleted verification form directly to the Board1 Educational frequest that yot schoolprovide an officialtanscflpt direcflyjo flanscripa :j1th Rnard

213 • tanimols CheckList Name it Instructiobs - - Contactthç ABGC or AMBG andrequest an official verification . of active candidate status be directly Exam Eligibility.. sent to the Board. This is only ±eprireclii’you are applyingfor a proiisionai genetic counselor license; . Contact the licensing authoritiesof the sWes, territorie or

. countrieswhere you hold or have ever held a license, certificate, . permit,registration or other authorizationto practice a health- related profession (ihethenctive, inactive, expired Left f Good or durrent). and.requestletters of good standing/verificationof licensure in.. 211 g OGS ‘ thatstate Orjurisdicfion.The lettermust include the following:

- license issue and ekpiration date, license status (current or expired) and disciplinarystaliding. The Letter(s)of good

‘ Ktandingmust be sent directly to the Board. . Youwill need to upload, whereprompted, proof of professional liabilityinsurance coveragethrough self-insurance,personally purchased insurance or insuranceprovided by your employer for [Wdpradflce the minimwn amount of $1,000,000.00pei?occurrence or claims Insurance made. This proof of insurance/certificate must include your name and indicate that you are covered under this policy while performing genetic counseling,services in the

• Commonwealtk of Penns’lvania.

• 1atiànal Cerdficaffân from the AmericanBoard of Genetic r1atlonal Counseling(ABGC) or the AmericanBoard of Medical Genetics Certification (ABMG).is required. Proof of certificationmust be sent’directly

. to the Pennsylvania Board. Please upload a Curriculum Vitae/Resumelisting all periods of employmentor unemployment(i.e., child rearing,research, etc.) . ,. from graduation from’yourhighest level ofeducation to present Resume/Curriculum (the education completed which qualifiesS’oufor this license). Vitae The list must be in chronologicalorder,includingthe name, city

. and state of the employer,.datesof employmentor advanced

• education/training (include the month and year), and description

• of the practice activity

3,3 1W3112019 Evaluationresults:

Board/Commission: OsteopathicMedicine - License Type: Ostopathic GeneticCounselor -1-9ën9 Rwis’â(W ObtainedBy:Applicaffon (3eje?,t. Cc.&nsjor i j’ I CheckList Name Instructions

[ ! If thisappliàation is not completedwithin sixmonths,updates of certainsectionsof the application andsupoi1ingdocuments will be required. If applicable,background check documentscannot be - ‘olderthan 90 days from the date.of issuance.if this application js Applicadon iotcompleted within one year, youwill be requiredto complete a [eW application and resubmit the applicationfee. You may not icticein the Commonwealthof Pennsylvaniauntilyou have ten issueda’liàenie,certificate,regislration,.permior thorizafion. 4si cSç?c\¾c(n& Castr applicationfee of $59td iñequire1P1easenote that all fres nonreflmdable.. ..$1i1. cc Certification of An 4a oc ‘tC6oo is nquct3 {br Supervise L Os4ecps4ht Temp fjvi’scorn Ge,Mc. Caisjr Ict . •. J1 health-relatedlicensees!cèrflficatebold rs ad fihieial. . directors are considered “mandatoryreporters” under section 6311 • .- allof the Child Protective Services Law (23 PS. § 6311). Therefore, personsapplyingThrissuance of an initial license or certificate ‘ frém any of the health-relàtedboards (except the State Boaid of ‘

. VeterinaryMedicine) or from the StateBoard of Funeral Directors . are required to complete,’as a conditionof licensure,3 hours of approvedtraining by the Departmentof Human Services Child Abuse CE (DHS) the-topicof.chlld abuse recognhiàn and reporting.Alter you’

. ave completedthe required course,the,approvedprávider will .• electronicallysubmit your name, date of attendance,etc. tothe

• 3ureau. For that reason, it is imperativethatyou register for the courstusing the informationprovided‘onyor applicatiçn for ‘ Ucenure/cerdflcation. A list of DHS-approvedchildabus’e

. . iducadon providers cà be found onthe Dej,ahment of State Website.

113 1013112019 j__Checklist Name_U Instructions Provide a recent CriminalHistory Records Check(CHRC from the state police or other state agency that is the official repository for criminal history record information for every state in which ou have lived, worked, or completed professional ñining/studies.for the past.flve (5)ypars The report(s)mustbe dated within 90 days of the date,the applicationis submitted. For applicantsliving, working, or completingträiningfswdies in Pennsylvania,your CHROrequest ‘willbe automatically submitted the Pennsylvania StatePolice upon submission of ‘ to this application. The PATCHfee will beineJuded at checkout’ YourPA CHRCwill be sent irectly to the Board/Commission.’ Youwill be notified if ad&tionalactign is required. For c ,. individualsliving, orldng, or completingtraining/studies outside ofPennsylvania during the past five (5)years, in lieu Ofobtirnng Cli k mdividualstate background checks,you may electto provide BOTH a state CURt from the statein which youâurrenffyreside, ANt ydur,FSI IdentityHistory SummaryChàdc available at s:llwww.ibi.govfservices/ciis/identity-historysumxnary

checks. ‘ . -

Pleasenote: For applicantsô&rentlyliving, working,or coiEplptingtraining/studiesin California, Arizona, or Ohio: Due

‘ tothe laws of these states,the Board is not an eligiblerecipient of CHRC’sor your CHRCwill not be issuedto you for upload to the ,:• . Board.Please btain your Federal Bureau of btesfigaUon (FBI) Identity History SummaryCheck available at the link noted

above. ‘ Piovide an offiéial notificationof informaflthr(SelfQuery) from th National PractitionerData Bait Pleaseitfer to the NPDB website foraddifional information.When you receiveth&’ Databank Report . . . ‘ . Response to your Self Quely,’ youwill need to upload it t your online application. The report will need tote uploaded,where pfornpted,in order to‘submityour application. Forwardthe Verificationof Edudailonform to your sdrnal/university to bomplete.Youare only requiredto the Education veriê level of cdqoadon completedwhiph qualifiesyou,for Verification this license. The school must return thecompletéd verification form JfrictlytotheBoard. Educational. R.equest*hatyour schoolprovide an official transcriptdincilyjo franscripta Ow Rnnrd 1013112019

flCheewstNamej Instructions - Contact the ABGC or AMBGand request an official verification of active candidate status be sent directly to the Board. This is Exam Eli ‘bliP” ‘ ‘ only tequired ifyou are applying for a provisional genetic counselor license. Contact the licensingauthorities of the státès, territories or countrieswhere you hold or have ever held a license, certificate, permit registration or other authorizationto practice a health

. relatedprofession (whether active, inactive, expired or current) and request letters of good standmg/venficafionof ficensurein Sta - g LIJ ‘ that state orjurisdiction. The-lettermust include the following: licenseissue and expirationdate, license status (cunent or expfred)and disciplinaiystanding. The letter(s) of good standink must be sent directly to the Board. Youwill neçd to upload,where prompted, proof of professional

. liability insuraiicecoveragethroughself-insurance, personally purchasedinsurance or insuranceprovided by your employerfor tWpracdce theminimum amount of $1,000,000.00per occurrence or claims [usurance made. This proof of insurance/certificate must include your whilename and mdi ate that you are covered under this policy performing genetic counseling services in the ‘ Commonwealth of Pennsylvania. National Certificaffénfrom the AmericanBoard of Genetic affon4 Counseling (ABGC) or the-AmericanBoard of Medical Genetics Certification (ABMO)is required. Proof of certificationmust be sent directly o the Pennsylvania Board. ,. Please upload a urricu1um Vitae/ResunieliEtingallperiods of employment-Orunemploynient(i.e., child rearing, research, etc.)

. &omgraduation,fromyour highest level ofèducation to present Resume/Curriculum (the education completedwhich qualifiesyou for this license). Vitae The list thust be in chronologicalorder,inoludingthe nïame,city

• and state-ofthe employer,.datesof employmentor advanced -

. education/training(include the month and year), anddescription of th practice activity

I OSTEOPATHIC PHYSICIAN RENEWAL Check D

SECTION U

C • C a

ADDRESS

NAME

verifying

it — — — —

appropriate

THE Please I period lntormat:on. recognItion am Street the No I License City Full EmaIl

will w;:I ‘

CHANGE-The

foe

exempt

practices

not be

Name

FOLLOWING

name

REPORTED

CHANGE

Address

Is review until

Address

retiring

you

required.

Number

4. 2. from 6. 1. 7. 5. 3. S. practicing

change

and October

answeryos

You

of the

from

jurisdiction? With revoked SInce charges, pled SInce

Since other odcupational professiona SInce the suspended agreed ocaupation registration SInce or Do please Do

prescribing LiST

reportJng —

ccn.nung

The rcgislration

ThE DUESTIONS name

you you

CME

practice

(I.e.,

Form

nob the this

31,

criminal

your required

your

your your

address

provide currently

not currently

INFORMATION

RENEWAL or

exception

above’s 2OZ$

to requirements. profession felony marriage

coniendere),

and

restricted?

Issued

or must to

questions

initial initial

but

education Initial

inilial

Initial

license,

matter

restricted Wi

other

apply

BUREAU

desire dispensIng

the or

occupational above

any MUST

have

hours

not

still application to

application

retain

application

msdemeanor,

certificate,

application

authorization

profession in

stab that you

the

certificate,

State

any any

Pennsylvara requirements to

2 APPLICATION

received

except reapply is BE

STATE

TO - of

through

place in one

has your current OF

oriurisdicion?

criminal

d completed

Beard ANSWERED

COMMONWEALTH

any

new

THEBOARD

sdpl;nary of

Medicai

PROFESSIONAL

you

been

Ucense,

official

or or

my oplolds. divorce for

far stale

BOARD

or and

probation

address

name

permit to

your are

last

holuding approved

DEPARTMENT license lest

charges completion

expunged a

your

last practice

pestec

after

Zip

stats

Assistance

orjurisdicticn

professional

currently pro

renewal,

charges

continuing

certificate, on

last

renewal,

decree —

renewal,

last vida

Code

the

and PRIOR

the on Renewal Questions

without —

pending en renewal, registration,

any

OSTEOPATHIC continuing

PHYSICIAN

jurisdiction. eap:ratlon active-retired

licensure

renewal,

profession

details

not the renewing,

ocr.dlng

AND

whichever

drug agency,

order

whichever

the

or verdict

Boaro’s legal permit,

whichever education on

must

and PENNSYLVANIA

occupational

whichever OCCUPATIONAL THIS

have law

AND file 2

STATE answered,

date recenis.

against

hours whicheve,

document had unresolved

a education

Medicare, do

With

be violations?

webstte registration

onurt,

status

you RENEWAL,

Is attach

occupation

you

accelerated

lncated

Is an

completed AND

certificates

later,

MEDICINE

of the

agreed

later,

your

State

Harrisburg P0 RETURN application hold,

which

You

Board•approvod

later,

license,

copies

Board.

later,

[hird

Indicating

in signed have

Is In SURGEON

pofessional

Box v,neypaovtst

have

any

below

must Note:

pain later, or

YOU

will

Board

have

AFFAIRS

party

have

rehabilitative

and

have

voluntary

you any

other

of state

certificate,

8417

you

TO:

eticw

management,

denied

submit

ar and You

completion have legal DO

fee

withdrawn

state

payor

you you

you retaking

been

orjurisd,ction?

outhortzaticn

request NOTNEED

mete

oT required.

are

dated.

ever

had

document(s). (00) you surrender orjudsdiction?

continuing

or occupational

Osteopathic

17105.8417

convicted

nct

disposition permit

photocopy

another

refused,

held,

provider

disciplinary

treat

had

inactive

rcqufred earned

Identification

Clici

application

your

a Immediate maiden

license,

authority?

education

lieu

(found

privileges or registration

REPORT

Vcense, status, (ARD),

practice for

DEA

for

action

of Generel

YOU

you

a this

name,

Medicine

disclose

daciphne?

QO disciplinary certificate,

for

guilly

legal

registration

family

answered ALREADY of certificale.

license

denied,

taken

to professional

etc,J

addiction

Board

document

orofession

child

AGAIN,

pied

members.

any eny

any

against

permit,

revoked.

renewal

guilty

reasons

ARD state criminal

abuse

denied

yes,

permit

or or or or

a ______

, j’au ‘il’ if answer yes to qudstioas 2 through 12,gSrvidedetail.; ANDmach copies of legal document(s). IF YOUALREADY REPORTEDTHE INFORMATIONTO THE BOARDPRIOR TO THISRENEWAL,YOUDO NOT NEEDTO REPORT ITAGAIN, 9. Since your initial application or your last renewal, whichever Is later, have you had practice privileges denied, revoked, suspended,_or restricted by a hospital or any health care facility? 10. Since your initial application or your last renewal, whichever is later, have you been charged by a hospital, universily, or research faci!iy with violatingresearch protocols, fats;fyingresearch, or engaging in other research miscojiduct? II. Since your InItial application or last renewal, whichever is later, have you engaged in the intemperate or habitual use or abuse of atcohol or narcotics, haliudnogeniss or other dregs or substances that may impa:r ;udgment or coordination? 12. SInce your Initial application or your last renewal, whichever is later, have you been the subject of a civilmalpractice lawsuit? If yes, please submit a copy of the entire Civil Complaint, which must Include the filing date and the date you were served.

‘if you previously reported the_complaint to the Board provide the docket number 13. Do you maintain current medical professional lisbility Insurance in the Commonwealth of Pennsylvania? If you answer “No” please provide an explanation or reason for an exemption request. 14. Have you met your continuing education requirements? Please revIew the continuIng education reculrements posted on the I . Boards website at wvw dns na.npvfost. Click on General Board Information. If you qualify for an exemption of the continuing I education requirements, answer yes to the question, You are required to retain your official continuing [,,,,,,,,, education certificates of completion earned for this lIcense renewal period until October 31, 2020. 15. Have you I completed at easl 2 hours of Board epprovod continuing education in pain management, Idenlilcation of addiction or I L...... the practices of prescribing or dispensing ol oploids? [,,,,, 16. Have you registered with the Pennsylvania Prescription Dreg Monitoring Program? —— —

SECTION B - VERIFICATiONOF INFORMATION

I verify mat this applicat:or. is in the original format as suppled by the Departvent of State and has not been altered or ctherwise modified in any way. I am aware of the criminal penalties for tampering th punac records or infcrmatort under IS Pa CS. §4911.

I verify that the statements in this application are true and correct to the best of my knowledge, information and belief. I understand that false statements are made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authonties) and may result in the suspensfcn, revocation or denial of my license, certificate, permit or registration.

Signature of Licensee (Mandatory): Date: cO[rO EXPIRATIONDATE:4 October3i, • .- .-. FEE - Payable to “COMMONWEALTHOFPENNSYLVANIA”+ &fl,OO (NON REFUNDABLE) Write your license number on your payment A $20;OQfee willbe assessed for returned payments.

LATEFEE —$5.00 per month, pr part of a monThwill bE âssëssed If postmarked AFtER 10-31-18

PRACflC1NQ ON AN EXPIREDLICENSE MAYRESULT IN DISCIPLINARYACUØNS ANDADDITIONALMONETARVPENALTIES

To ENSURt YOU RECEIVE YOUR NEW LICENSE BEFORE It EXPIRES

2 COMMONWEALTHOF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS c7 STATE BOARD OF OSTEOPATHIC MEDICINE

RENEWAL APPLICATION — PHYSICIAN AND SURGEON (DO)

FuliName RETURNTO:

Street Address State Board of Osteopathic Medicine P0 Box 8417 City State Zip Code Harrisburg PA 171 05-8417

Email Address

License Number rCheckif appropriate

0 ADDRESS CHANGE — The address above Is a new address and not on file with the Board. of O NAMECHANGE — The name abcve is not the current flame on the Ucensure records. You must submit a photocopy a legal document indicating retaking a maiden name, etc.) • verifying name change (i.e., marriage certIficate, divorce decree or legal document of

date in&cated oeiow end requesi mactwo status. O I wit not be pramicing this profession in Pennsylvania afterthe expration No fee is required. Form must still be completed — questions answered. sinned and dated.

to active-retired stabs which wil allow me to treat immediate fam’y members. I o Iwillbe retiring from practice but desire place my license on am exempt from the CME requirements, except for completion of the 2 hours of Board-approved continuing education In child abuse recognition and reporting and 2 hours of Board approved continuing education in pain management, identification of addiction or the practices of proscribing or dispensing of oploids. Renewal must be completed and fee required,

SECTION A Please review the continuing education requirements posted on the Board’s website at fg,s.peqoviost, Click on General Board information. You are required to retain your official continuing education certificates of completion earned for this license renewal period until October 31, 20. alt THE FOLLOWINGQUESTIONS MUSTBE ANSWERED If you answer yes So questiOns 2 through 12, piovliie details AND attach coplds of legal documentfr. IFYOU ALREADY YES I NO REPORTED THE INFORMATIONTO THE BOARD PRIOR TO THIS RENEWAL,YOU DO NOT NEED TO REPORT IT AGAIN. With the exception of the one you are cutTenty renewng, do you hold, or have you ever held, a tcense, certificate, permit registration or othor authorization to practice a profession or occupation in any state or jurisdiction? If you answered yes, please provide the profession and state orjurlsdlction. LIST: — 2. SInce your Initial application or last renewal, whichever is later, have you had diocipinary action taken against a professional or occupational license, certificate, permit, registration or other authorization to practice a profession or — ccipaIion issued to you in any state orJud diction or have you agreed to voluntary surrender in iie, of disc’pine? 3. Do yov currently have any disciplinary charges pending against your pmfes&onal or occupational license, certificate, permit or registration in any state or jurisdiction? 4. Since your initial application or last renewal, whichever Is later, have you withdrawn an application for a professional or occupational license, certificate, permit or registration, had an application denied or refused, or for disciplInary reasons agreed not to apply or reappty far a prcfesslonal or occupational license, certificate permit or registration In any state or jurisdiction? 5, SInce your Initial application or last renewal whichever Is later, have you been convicted (Foundguilty, pled guilty or pled nob contendere), received probation without verdict or accelerated rehabilitative disposition (ARD),es to any criminal charges, felony or misdemeanor, including any drug law violations? Note: You are not required to disclose any ARD or — other criminal mater that has been expunged by order of a court. 6. Do you currently have any criminal charges pending and unresolved In any state or jurisdiction?

7. Since your Initial application or your last renewal, whichever is lator, have you had your DEA registration denied, revolted or restricted? 8. Since your inidal application or your last renewal, whichever Is later, have you had provider pri½eges deniod, revoked, — suspended or restricted by a Medca Assistance agency, Medicare. th’rd party payor or anothereuthority?

Signature

revocation

statements

SECTION

Ej_

;

verify

aware

FEE

that that

—

are this

Payable

the

writ; the denial

—

LATE

Licensee

made

apptcaticn

VERIFICATION

crimInal

statements

REPORTED

of you

your

15.

subject

16.

PEE

13.

12.

Ii.

ID.

answeryas

penalties

lIcense license,

Have continuing

addiction

Have

education

Boards Have

Do lawsuit?

Since

you

abuse

Since

suspended,

(Mandatory): Since

—$5 ‘Ne”

SInce

‘COMMONWEALTh

research

THE

you

DISCIPLINARY

this

the

were

tho

you

please

you

your

ENSURE • certificate,

your

foriampedng

number

previously

webue

original

maintain

INFORMATION

application

penalties

alhol

per

registered

fo.questfoos

met

served.

PRACTICING complotad

certificates

education

the yes,

INFORMATION

facility

InItial

initial

provide

your

month,

restricted

practices

format

please

current

permit

YOU application

______-______

application

with

application

continuing

narcotcs,

reported

with

are

wltn

your

16 an

ACTIONS

requirements,

violating

RETURN

RECEIVE

submIt

the

true

PeGS. explanation

pubic least

thmugh

medical

comptetlon

suppfed

part

registration.

prescribrg

payment

THE

Pennsylvania

EXPIRATION

the

and

hospital

education hallucinogenics

PENNSYLVANIA”

recordsor

research

complaInt

hours BOARD

last

professional

your

AND

your

corned copy

12,

BY:.

YOUR

4904

EXPIRED

month

provide

the or or

answer

earned renewal,

last

requirements? last

ADDITIONAL

any

reason

(relating

dispensing protocols,

Department

Click

to Prescription

PRIOR

information

the

NEW Board

OCTOBER

$20

renewal,

renewal, renewal,

health

the

Will

DATE:

for

yes

details

liability

entIre

the

liCENSE

whichever

other

for

besl

this

LIQN$E

appzved

General

Board

care

falsifying

fee

unsworn

whIchever

THIS

assessed drugs

the

whichever

Civil

under

whichever

AND

license

Drug insurance

opioids?

exemption

Please

iadtty?

MONETARY.

Slate

will

1.20*

question.

provide

MAY

RENEWAL,

ComplaInt,

attach

Board

Monitoring

lSPa.C.S.

research,

coruinuing

knowledge,

BEFOREIT

later,

falsification

and

renewal substances

review

qNpN

asses

October

RESULT

has

Information. the

copies

request.

later,

postmarked have

Ihe

later,

You

the

docket

not

Program?

PENALTIES.

period

which

Commonwealth

§4911.

YOU

education

you

engaging

have

information

continuing

are

have

that

have

been

Date:

EXPIRES

authorities)

for

kgàl

engaged

required

number

must

may

until you

31,

you

aileed

returned

NOT

AFTER

you

documenfl).

had in

______

impairjudgment

been

October31

2E.: been

education

include

REFUNDABLE)

and other

______

pain

NEED

to practice

qualify

and

the

charged

the

retain

otherwise

belief.

Pennsylvania?

research

management,

payments

10-31

intemperate

may

the

subject requlremenls

•

for

privileges

2020.

your

REPORT

filing

result

YOU

mcdified

misconduct?

understand

coordination?

official

exemption

hoital,

date

ALREADY denied,

—______

civil

tentificaton

the

habitual

posted

and

you

AGAIN.

continuing

suepension. malpractice

—-

any

university,

that

the

revoked.

answer

way.

use

date

false

the

or I COMMONWEALTHOF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS STATE BOARD OF OSTEOPATHIC MEDICINE

RENEWAL APPLICATION — PHYSICIAN AND SURGEON (DO)

Full Name RETURN TO:

Street Address State Board of Osteopathic MedIcIne PD Box 8417 City State Zip Code Harrisburg, PA 17105-8417

Email Address

License Number check if appropriate

U ADDRESS CHANGE —The address above is a new address and not on lila with the Board.

C NAMECHANGE — The name above is not the current name on the licensure records. You must submit a photocopy of a legal document verifying name change (I.e., marriage cértificato, divorce decree or legal document indicating retaking of a maiden name, etc.)

indicated below and request inactive C I willnot be practicing this profession in Pennsylvania after the expiration date status. No feels requIred. Form must still be completed — cuestions answered, signed and dated.

allow I U I willbe retiring from practice but desire to place my license on active-retired stsius which wilt me to treat immediate family members. am exempt frcrn he CME requiremerts. except for completion of the 2 hours of Board-approved continuing education in child abuse recogniLion and reporting and 2 hours of Board approved continuing education in pain management, Identification of addiction or the practices of prescribing or dispensing of oploids. Renewal must be completed and fee required.

SECTION A • Please review the continuing education requirements posted on the Boards websita at wwwdos,na.ocv!osi. Click on General Board Information. You are required to retain your official continuing educatIon certificates of completion earned for this license renewal period until October 31, 20.

THE FOLLOWINGQUESTIONS MUST BE ANSWERED if you answ4r yes to questiwls 2Etrugh 12. provIde details ANDauach cop.’as of legal document(s). IF YOU ALREADY YES NO REPORTED THE INFORMATIONTO THE BOARD PRIOR TO THISRENEWAL YOU DO NOT NEED TO REPORT IT AGAIN. 1. With the exception of he on you are currently renewing, do you hold, or have you ever held, a license, certificate, permit, registration or other authorization to practice a profession or occupation In any stale or jurisdiction? if you answered yes, please provide the profession and state orjurlsdiction. LIST: — 2. SInce your initial application or last renewal, whichever is later, have you had disciplinary action taken against a professional or occupational hcense, certificate, permit, registration or other authorization to practice a profession or — occupation issued to you In any slate or jurisdiction or have you agreed to voluntary surrender in lieu of discipline? 3. Do you currently have any disciplinary charges pending against your professional or ocoupalional license, certificate, permit or registration Inany stale or jurisdiction? 4. SInce your Initial application or last renewal, whichever is later, have you withdrawn an application for a professional or occupational license, cortiricate, permit or registration, had en application denied or refused, or for disciplinary reasons agreed not to apply or reapply for a professional or occupotionai license, certificate, permit or registration in any state or jurisdiction? 5, Since your initIal application or last renewal, whichever is later, have you been convicted (found guiity. pied guilty or pled noio contandere), received probalion without verdict or accelerated rehabilitative disposition fARD), as to any criminal charges, felony or msdemeanor. including any drug law violations? Note: You are not regjired to disclose any ARO or other criminal matter that has been expunged by order of a court. 6. Do you currently have any crininal charges pend;ng and unresoved in any state or jixisdction?

7. Since yeur initial application or your last renewal, whichever is later, have you had your DEA registration denied, revoked or restricted? 8. Since your initial application or your last renewal, whichever is later, have you had provider privileges denies, revoked, — suspended or restricted by a Medical Assstsnce agency, Medicare. third party payor or another authority?

1 -.. ______

Ifyou answer yes to questions 2 through 12, providEdetails ANDattach copies of leáai document(s). IF YOU ALREADY REPORTED THE INFORMATION TO THE BOARD PRIOR TO THIS RENEWAL, YOUDO NOT NEEDTO REPORT 9. SInce your Initial application or your last renewal, whichever Is later, have you had practice privileges denied, revoked, suspended, or restrIcted by a hosptal or any health care facility? 10. Since your initial application or your last renewal, whichever Is later, have you been charged by a hospital, university, or research_facility with vIolatingresearch protocols, falsifying research, or engaging in other research misconduct? 11. Slnea your InitIal application or last renewal, whichever Is later, have you engaged in the intemperate or habitual use or abuse of alcohol or narcotics haliucinogenics or other drugs or substances that may impair judgmcnt or coordInation? 12. Since your Initial application or your last renewal, whichever Is later, have you been the subjecl of a civil malpractice lawsuit? If yes, please submit a copy of the entire Clvii Complaint, which must Include the filing date and the date vet’ were served.

— “If you previously reported the complaint to the Board provldeihe docket number — -- 13. Do you maintain current medIcal professional liabilIty insurance in the Commonwealth or Pennsylvania? if you answer ‘No” please provide an explanation or reason for an exemption request. 14. Have you met your continuing education requirements? Please review the continuing education requirements posted on the Boards websita at w4ps.pp gnvfust. Click oii General Board InformatIon. if you qualify for an exemption of the continuing education requirements, answer yes to the question, You are required to retaIn your offlciai continuing education cartificates of completion earned (or (lila license renewal period until October 31, 2020. IS. Have you completed at least 2 hours o Board approved ccnUnuing education in pain maregemer,t. identiftation of adc:ctiot or the practices of prescribing or disper&ng of cpio4si 16, Have you registered with the Pennsylvania Prescription Drug Monitoring Program?

SECTIONB — VERIFICATION OF INFORMATION

I verify that this applicaton is In the original format as suppliso by tho Department of State 31d has not been altered or otheRve modified in any way. I am aware of the crimnai penalties fortampering with public records or information under 18 Fa.C.S. § 4911.

I verfy That the statements in this appkcation are true and correct to the best a’ my krowledge. informaticn and beilef. I understand that false stalemenis are made subject to the pena;Ues or 15 Pe.C.S. § 4904 (relating to unsworn falsification to authorities) and may resut in the suspension. revocation or denial of my lisense, certificate, penit orrgistration.

Signature of Licensee (Mandatory): Date: PITION bAfl: October3l,..’r FEE — Payable to 11COMMONwEm OF PENNSYLVANIA” 4 $a00 (NONREFUNDABLE) -. Write yourlio.nse number on your payment. A $2OOOfee wiff be assessed farmwrned payments. kSO LATEFEE — $5.O per month, or pafl of a mqnth wilt bdtdessed if postmatked AFTER 103116

PRACTICINGONAN EXPIREDLiCENSEMAYRESULTIN DISCIPLINARY ACTIONS AND ADDITIONAL MONETARYPENALTIES

TO ENSUREYOURECEIVEYOURNEW LICENSEBEFOREIT EXPIRES .- .. RETURNBY:.’ OCTOBER 1,20*

2 PHYSICIAN ASSISTANT RENEWAL COMMONWEN.ThOFPENÜSYLVANIA DEPMnIENT OFSTATE BUREAUOFPRorssIoNAL MD OccupAnoNakFpzRa $TA1EBOA?DOFOSTEOPATHICMEDICINE

HENEWALAPPLICATION-PHYSICL4NASSISTANT

RflJRNTO: FulNn St4e Board of Osteopathic Medicine Street Adthvn PG 8ox5417 Haffisburg,.PA 171053417

City Stab ZpCode

EmailMdruas

Ucedaa Number

Chick Ifappropdats

n ADDRESSCHANGE—moadthnn above isa newadthessid not on filewith the aaad.

a NPMECHANGE-Thenameabove tonotihe current name i,thejlcenwffi recodia. You must submit a photocopyofa tgaIdocument veftlng mamachange I.a. mirdane Ce, Waste, divorce dene.or legal document lndlcaUn retaking ala maiden name, etc.)

C I willnotbe pmwnb thisgnofes&onhi Pennsylvaniaaller TheepImUon dale IndIcated belowand requesInacUstaw& Na fbi is requIred. Foen must .1111be eamIabd—nuestlons answmd, signed and dated.

SECTIONA • FIBS revIewthe raiilinuingedutiun requhementspooled on te Soard’s weWte at vN.dn-óe2Wost. CJkkonGederelBoard lnniiaUn You amrequired to totem youroffic!ulcontinuinc edutlon certificates otcomptation earned farthis license renewal perioduntilOctubara1,2D3We :‘ • ThE FOLLOWINGUCENSERENEWALQUES11ONSMUETBEMSWEREP ‘ YES NO you anmwyesfa questions 2 thrmiph IZ pmwdedet&ls A?JDauach copMs of kgal document(s). 1FYOUALREADY’ REPORTEDThE INFORMAtONTOTHEBOARDPRIORTOTHISRENEWAL.YOUDONOTNEEb TOREPORTrAGNN. ‘I WHitViaexceptIon ofTheoniyou am currentlyjeneijing.doyou hold,or havetu everheld,a tone, certificate, permit regislmfldn or other auliiodmtlonto predue a pmhsdon.orccwpauon Inanystale ocjwisdldtlon?Ifyou answered yes, plead. provide IIwprofnaion and state orjudsdlcffon, UST: 2. S&ce iow Initial eppflcahton or Isat renewal, whictaver Is later, have you hd dIs4,Thiaryactbn tekin’-agohista’ — pmbormI 0504,a&n or npedonal llnde, cottfioot%.pennk, regisnifon or other aufrtalbn to pracffc a pmfe&oo or Issued to you hi ahystob orjwbdbbri orhave you agreed to vblwitoysunender Inlieuof dlselpine? 3. Doyou.tunwitly haveanydlsdplkwrydiergea pending against your profassienalor occupational flcense,ceitflcete, ‘ ‘ panoftarreglsntlon Inwiy.ste orfuflsdldai? - -. —. 4.. SInce your InItial application at last inewsI, whichever Ic later, have you wtthdmwnen Appicatlonfor a pmbtstonalor occupational license, tatijicata permit or reglatmtlon, had an,applicationdenied or refused,or for

• , dhdpllnary rtssons agmod not to apply or reappiy for a proFessional cc oxpatbnal license, cectificalo,prnnit or mØThUan In any state orjudsdlcdon? — 5. SInce ycurlnlflal eppilcatlon or laM renewal, whichever Is later, have tu beanconvIcted(foundgully, pladguiJwor pied nob coMendeje mcded pmbavon without veidctbr accelerated rehabflltefvedisposition (MO), as to any edmInalchargai fbbiy or mitdsmewtr, todunô any thug law vIolations? Note:Youam natrequtredla diadosenny , MiDorator wimina!metierthat has been enged by order of a ccañ: B. Dayodam&t y.Iiaveany criminalcharges pending and urucsötved Inany state ocjurtsdicllon?

7. Since your Initial eppllcadon’or your last renewal, whichever Is later, have you had yourDEAIegTSnUOndeified, mvokorresfficted7 . ,

• 8. Since yaw Initial apçHceUän or yoir last newel, whichever Ii later, have youhadpzover privIlegesdenied,

‘ ‘revoked,suspended inractad bye MedicelAnalalanceagency. Medicare,thtd past’payer ornthar aumodw? - 9. SInce your Initial appllclSlad or your heatrenewal, wtilaluvar Is later, havetu Md practice pihilegea denied, — ravcke. susperidod, onresulded by a hospital orany healthcam facility? I ______‘ ______

•n. •u Vcu enwnr yes to quntions 2Thmugh1 providedeW/s ANDattub copies of legal dooumsnffs). WYDUALREADY REPORTEDTHEINFORMATIONTOTN? BOARDPRIORTOThis RENEWAL.YOUDONOTNEEDTO REPORT ITAGAIH. ID. SInce yoUr Initial çpflcatlon or your last tenewal, whichever Is bier, have you been tharged bye hospil, university, or nessarcb fadity with tlolathg research pitioxte, 1af&Ftngresearch, or aigaging fri other reseadi misconduct? 11. SInce your linEal apçJieatlon or last renewal, whichever Is kIss, have you engagàd m the Intempaffi or hebmiel ase or abuse of aIxlioI or isreoica. bs&idnogenl or other drum or ci,bsbns tat nay kapek Judgment or coordlnalon? 12. Since your Initial eppflation or your fat renewal, whichever is later, have you been the abject of a clvi malpracticelawsuit? if yes, please submits copy of die sofia CMI Complaint, which must Includethe flhinqdate end the data von wars nrnd.

‘flYyou pravloueiy reported lbs compkintto the Ecord providethe docbt number 13. Doyou maintainojrent medIc pitfasslonal liabilityInsurance Inthe CommonwealthclPinnsylvênta? if you sower °No”, please providean explanation or mason far art exemption request

• 14. Have you completed at least 2 boUts of aoard aptved conVnutngeduceOcn In pain management, Menuficafi, of addictiono(the pradicas cFprescflblngor dispensing of opbds?

15. Pa youholdirnnnt cudficadontidththe NCOI’A?

16. He’o you regietwed withthe PensØvwla Prescdpton OnçP.brJiodlQProgram?

SECTIONS- VERIFICATION OF INFORMATION lve&ydatthisapp&aton isinthe wlfnalasaupdbytheDepvtmeniofSoaidhinotbeanettradoroViemvfsemoditedlnanywty. i em awareofthe niminal penaNas far bmpedng withpio records ormnfarmatlonunSer18 PatS. § 4B11.

to of kna.ledgo,lnformatlonand belief. i telea I verifythat to atesawits In lids appUIon Wa true and correct the best my understendtim statementsore made eubJo late penalhiesof IS PaC.S. § 4904 (relatingto unswomfaisificotionto authoilifee)end mayresultInthe suspension, revocationor deals!ofmyIcense, certtte, penn!torreistaUon.

$ianeijro oflicørisoe (Mandatorç_ —______9 9r . rvftJtflt - -

- ‘WI—I- N- ‘ -

--IA.-L.-.I .ifr -.. - -, zr—--4-r..-i, . - C’a ‘tL g4 —n.—-—-— wzi — z’Z__’ - .J_ ___ _•• —• aL.* t •‘ -______

2 H CoMMONWEALThOFPENNSYLVANIA

I I) BUREAUor PROFESSIONALMD OCCUPATIONALAIFMRS STATEBOARDOFOSTEOPATHICMEDICINE

RENEWALAPPliCATION— PHYSICIANASSISTANT

RETURNTO: Full Mama State BoardofOsteopathic Medicine Address P0 Box 8417 HIebu, PA 17105-8417

City Stab pCod,

EmailMdrtss

license Number [ck PappreMate

U ADORESSCHANGE—Theaddress obeys tomow address and not an file with the Board. n NAMECHANGE-The name stove Isnot theond name onthe Iicenswe records. You must eubrefta photocopy ate IeaI doanent ve4yin namachanrn (Is... pQcediflcete, maIden narno. eta)

U IwliInotbe preeddeg dthvfeW friPenosylvsab eRr the emdon data indIed balmyandrtçuart Inedivestatus. No TeeIs required. Font, nwa dlii be carealetod —questions arrnwered. signed and dated.

SECTIONA • Pleasiravlew the conVrung edua&n requlamenb posted all the ,wabsIe a w.wSo.éa.bovIost tick on Gtnnl Board infxlladon, Youam required bretaln your oWcIaIconunulpg education ceitflcetes oloompiouon earnedfar iNs Ucanaerenewal period until October31, 2O28q • —.ThEFOLLOWINGUCEtISE ItENtWAL QUESTiONSMUSTBEANSWF wyou ennsr yes to QUeS*DS mmugi, n, pmvwe details ANDiffach copies of legaldocument(s).IF YOUALREADY REPORTEDThE IWORNAnONTO THEBOARDPRIORTOTWa RENEWAL,YOUDONOTNEEDTOREPORTITAGL’N. .1. Wlh the nptn of ThaoneyouasswnwrdyrwiwIng,doyouhold, or have you ever beta,a Irse, cad)file, permit r4slra&n or othweubiothaflon to ped a pmfessbn orocUon Intrw sale crjurlsdcdon? Ifyou answered yea, please pquvlde the prefreslon and able orjofladlclkn. LIST: 2. Since yew InNial eppilsellea or bat ranowol, wNcbevar It Itler. have you had dItclpUnazyeti taken agabiet a pmfeasioM or ocaipaVonsl ioena, l1ate, psmtZ reglat-adona other au&dzfln to pmc&e a piofenbn or ocavatk,n Inaed Wyou biany sate wIwtsdIc’Jonor hav youagtaed to vo&mtsysunohdor frilieu of thdpflao7 3. Do you DJITinUy have erw dkSIJTIaYYdiwás pending flt your picleasin or otaipafansi tcenho. cmctta, rtmft otrtgIsUado hanyatoWoTJuddn? 4. SInce your InItial cppNcstion a last renewal, whicin, is later, hay! you Wlhdtawit an sppUton for a profeWonal or ocojpaucnat Uconsa, certificate, permit or regisifaticit, had ‘an application denied or refused, a fat dlsdplbiaqmasons agreed not to apfli or’mspplyfor a pMes&on&or acalpationai license, certificate, permit or mgtat,Oon Lianystate orjuddictionl 5. SInes your Initial eppflcaffon or last rincwai.ihlchever I; Iatkr, have you been donVcled(foundgullt pled gibyor pled nero mntendem), mcslred probacn wlthqut vsrdt or aereted mhahillallya &aposldon (ARD).as to eny afrrdnelcharges, felony or mbdomeanor Indudlng any drug law1oiaUons? NotrnYouare not mqurr to disclosearty ARDor ether atmhial niatisremi hambean aimged by orderci a court . - 6. Coyou arwmiftyhaweany almlnardiasges pendingand uniascivid Ii pay slate Driurisdiction?

7. SInes your Initial eppliUon or your last renewal, whichaver Is later, have you had your flEA riahIen defiled, iewokedanatlcjed? 151 S. Since yaw inItial applicatIon or your renewal, whichever Is late,, have you had previderpdvlieaesdenied, ravukadstspaxed amsbided bya MedicalAssistanceagency,Medicare,thirdponypayororanathrauthoq 0, Sn initial applIcation or your lest renewal, whIchever Is later, have you bed practiceprMiegeedenied, • reubd. npCed, or resktctadbye hospitalorany health care fediky? I __

• ifytu answer ynb questIons2thmugh12,providi dcfew,ANP stash copiesof &gafdocument(s). IF YOUALREADY REPORTEDTHE INFDRMA11DNTo ThE BOARDPRIORTO This RENEWAI.,YOUDONOTNEED‘EUREPORTrTAGAIN. 10. SInce your inItial application or your last renewal, whichever isIaw, have you been thargad by a hosfbl. unlvetslty, or releardi faDliLywith goIatn researdi pctto(5, ft’sWjltç reasadi. engaghig h othe resasrdi mfscaadud? 11. SInce your lnRWlappflcauonor last rcnewaLwNchevn Is later. haveyo ensdth the intampetaloor hsblbuii • use & Ab(fle of uhxhol yr narllca, hafunOgrlc or other thugs or substances that may tpafr judgmentPr a,oidbmeon? 12. Sines iour Initial application or your leat renewal, whichever Is him, have you bean the subjectof a call mo!pa bwsuW?Ifyea, please submit a espy oldie entire CIVIlCemptaint.which wu5t Includethu fun deft and the date ‘geewereseived.

— ‘ilyou prevfevalyreporteddi. complalattothe Boezdprovidethe docketmanber . 13. Do you mahffi sunnl moc’talpmThssltnalliabilityinsuranceInthe mmcnnaIth of Pewsylva&a7 llyou answer — No”• Isasa provideen nplana&n or tenon for an exemption lequest

• 14. Have you onwblad at inst 2 hours of Beard epprovod nUnulno education In pain minagement, idantftnauon of oddidlon or the pmdlces of presuibmg or dispensing ci opkids?

15. Doyou hold cwrent csrtlEUon b%t WeNCCPA?

— 10. Hays you mgfstndv,th the Penms1vania PNsfllon DrugMonitoringPmgmm?

SECTIONB - VERIFICATIONOF INFORMATION

or I Iva-il’ Ihatthis appIIrzon is In the odglri,i formatas suppliedby the Drpethnent ci Slats and has notbeen slimed othwwsu modiflcdInanyway. aol awn of the cilmhwipenaltiesfor lampufrigwithubllc rasda crinfonsUort undt 18 Pa.C.6. §4911.

thoi1edge. I vfl that the sthtuncn fri Wa eppEtcn are &ae aM noct to 0e bni of my frrmadon aM beset i uhdetstand that fate tcma we made wect to the penafrlassf16 Pa.C.S, § 4804 (r&aUngto timewornMemna b aijthotdss) and may result Inthe giensIon, mi.vndon or dents!olmy icanse. ca’tiflte, pemm orregbflllon. wfUctnEo {Mtcktogy);______Date:

ft - ...... — U’” —

2 SECTION

C Chock fl

YES

ND ADDRESS t4E vepe wU lrapprcpñata — — — — — —

foe THE period inrorrnatlon. Please

License EwmllMdrsaa

Sflat cay not

FuR

tiO

CHANGE—The

Is be FOLLOWiNG

Nn required. pra:clng roviow unUl CHANGE—fle .

Addrees

REPOR1D ifywanuvuryn

Number change October31,

C. B. 4. 6. 0. S. You 2.

1. the • Form &is ntinu!ng Siacs D dbdpflnazy rsQokad SInce pled

r&okod. ARD alrnlnei revoked, SInce reglantion am aince professional

Do ccaipadon WIth pasmftorroglsfruffonln Sine. SInai prvfos*nal ponn. ensweted LISt LICENSE name (I.e.. pmrebn

ThE you you required must note or addrasa the yew your your

your your 2O5.n above your ouronCy marriage reafldm cther or

UWORMADON charges, amtnfty suspaided suspended, aosØon still

education contsndam), restricted? pa, RENEWAL Li Issued Initial

reasons quesekac InWai-eppilcaflon

Initial Initial Initial or or

RENEWAL to criminal inhbi

BuREAu any is

in above ba please not ratajn ocaipationol oaaipe&nel

Par Mn felony cerflcate. have comeMad—

atate application to .

application orothrm,thorkatlon appilaiffon of appilcatioa Urn or raqubemants oppiicatlon

,sivonIa you or agreed to the maIW any

5mm

your CUES1JONS

2 any provide any ortJdWItion? rntricled mint a

or or reGalved

In t6’oriqh onojvu

COMMONWEALTh new otmtnal mlsdnsior,

toted any aMa

APPLICATION

PROFESSIONALAND dbdpflnsry omolal ThE

t aol divorce &ansa, Ilnaa,

after

Bwsu

or address name cr uesttons stale or the or or

by has orjwisdiodon? BOARD to by probation

last am posted 1 your lpCode ctiaree bet

the your your

a continuing profusion apply a MUST on or been last -ectiflenle, anntb’

Medidal pruvf* decree renewaIwhlehavar hospital certificate,

pkoton

or jurlaWWon reneni, bit dines end (h Ia last last on lndLng PWOR aiunnd. or swerged renewal, pwudmg

OSTEOPAThiC p,adIa BE berate ii.lthuS

Bit renewal, lb.

not

I ‘

Assistance renewal, rehowal. or UsWIsAND . reuiunfng.

— OF ANBWtREU education and — Boards JeaI on pending any

data whlthavar.Ie permIt TO

PHYSICIAN OF permit

PENNSYLVANIA erhave any and

OCCUPAEONAI.AFMIRS file verdict state This by lmdth whlchevà STATE resents. pMaion - Mr

IndIcated singed whichever decwnent thug tmresclved whichever whichever with order websfle do reglsbaffon

agency, or a against orjwlsdldflort RENEWAL, you certificates Is attach or professional 4ti, tsm MWICINE rastraUon. law

the Islet, of and

State P0 Hafficburg,

RETURN

You acc&ntad agreed

below later, tdu. a or atwadoc.an.oavIogt vicidona? belly?

Board. ASSISTANT Is bzdksflnn your

Medicare, is ceut dated. copies

Box ccoipa6on In

must have

is I. later, later, or any or Board

and hr’s

to later, later, profeselonal YOU of other have

9417

voluntary or you had

TO:

submIt state campleuan of

request have have you rehabbhtaffve

thUd ow.rpadons1 fldmg Noee have kgeldoewnnt(SA have been

PA vu an ajthethaIIon of in arjwlsdictlon? had you NT

party arw apØicaffon

a you-

Osteopathic aver

171054417

InaDve

surrender You you nvlad you,

photocopy or - had d1sdpilnery state JiAly

NEED eta

payoror i’,l earned held, occjpational are had had Click your dispeslgon ilcenas, idman

flrfsxfctb,? sfls. mstân ml to providar pmcU a TO

(found In daied acne, DtAregisntian on for pralce requked

anoth Ieu

of. REPORTUAGA3L. ocou IF Sansi an this ontcaIe,

Medicine nine, otdlsdpllna? guilty, YOU

lapel bcensa, (AR!)), rr *lIeges pdvliegee appbcallon cartPcalo,

llcaina

authority? a taken to i1aoay rebsad, ALREADY

profession document Board pied if st dsdosa you as ceWftale, pemill against gtthyor renewal denIed, dented. denied, to or hr any any for or or a a

I I. -

revocation am Fjtse I statnnta SECTIONS I

aafl’

G 4.r_etr vezl’

vet

aware

that

that —

ordenlal ‘fl’r

L’WP,9!flS

thIs

the

e ‘J’Øê

• — application

made S

cdnlnal

statements

VERIFICATION -.

if REPORTED

you ..-tEs

subjeti

.Aa;’>

my .

16. 14. 12. 15. Ii. 10. 13-

penslti

u-rrrgar

Wt*kRJØ

* ensnrss

tInae,

fri

andthedabi.vuwnssrve4 Have addiclion Have “U ‘No’. Do m&pmc*e jdInatlan7 use SInce SInes DoyouholddmflcertlflcaffonwlththeNCcpA? mlbcoaduct? Since wdvefslly, In

thb 4.

the

THE

>o,,

you

the •+t5i

catificate,

for

you

you .,

please orIginal

your

ëpØcatlon

your

peqet

mak,Wn abuse

INFORMAUON pr.viou,lyrepoitadthe

tampeiln

to OF

ortlQpmc’dces

iegteud

mpleIad

lawsuit? quOffôns

frKlaI I

Jnitlal

Initial

INFORMATlON

provide

format

roseardi -.

pemift

ctwonf

ailS -J

alhcl

appllcati&i with

applIcation with

applicatlen

I!yn,.plbaeo

thie or

PI.C.S

‘I publlorecordt

supplied

IadNly

medli

the least

t&cugh

nglabeUt

axpianalion

•t ‘--4r.a

presolbing

THE

Pennsylvania

nara,tlcs.

2 —

or with

correct

hours

BOARD or professional by

compiahitto

4904

12,

bat

.STCZ-tk.

submits ttio

your

vfdeling

or ‘s4prç-

(relatig urdJ5ariskag

of renewal,

oWdedcUs Oepwtiiont

haflunagenIca

IrdonneOon

mason PRIOR

Beard last

PrescrUon

bat

tie

PablZty copy

researsh

the ranewal, rjv. best

nneweL

whlcbpver

appmvad TO

force

tmswom

Board a

oVlla n

tinder of

THiS

b,surance’bi

AND

Stale

Dmg

opbids?

exemption pretocak

whlthañr

whichever

pmvlde

entire

RENEWAL, 16

knoviedge. -.

attach nVnuIng

tWsthUcn

othu

Manllzrlng

and

is ‘-.

PaC.5.

lator,

rsw -ra,Z’w-

has

Clvi)

the

coplss dmgs

the

bI&&frc

.4U’

Oclnhi

request

not

Is w1jii

havo

CDmmonwcalm

education

docket Compialnt,

YOU

Program?

hbmton t

la 4911, bier,

bean ______—

later,

vIfrguJ

authorfdes) . I you

substances

DO I

msewdi

altered

ntrber

have

engaged

have

HOT

dot

whldi

e.id

paIn *1_aa.a.,_M.._.4,J.

you

s.s

NEED

at you

and

umin4s).

r - O.

ballet otherwise

Pcnns)*anla?

that

management,

hem

must -

nay

been angagTng

the a

may

mail

Intemperate

thasged

Include

REPORT

the

I IF -

nadlifed

understand

Impair

YOU

Eu4act

w,. In -

Ida

oUi the

U the

by ALREADY

Judgment you

suspension,

a fWne

AGAiN:

-‘-1 licaton

any

reacardi that

hospital,

eanvar inbiwal

way.

date

false

of or

I ACUPUNCTURIST RENEWAL * COMMONWEALThOFPENNSYLVANIA OdQ DEPARmEwOFSTATE BUREAUOFPROFESSIONALANDOCCUPAUONALAFFAIRS STAlE OARO OPOSTEOPAThICMEDIciNE

- RENEWAL APPLiCATION- ACUPUNCTURIST

Fufl Name - - RETURNTO:

SfreetAddma - - Slate Board of Osteopathic Medicine PD Dcx 8411 CRy State ZIp Code -Herriebwg,.PA 17105-8417

EmaflMdmis

License Nwnbn

Chedc Ifeppropdate . - 0 ADDRESS0W40E -The Mdmn shove lee newaddrneandnot oil fil, withthe board.

Cl NAMECHANGE-The nameabove Istheaatent name on the Scensuramid,. You mustmthmlta photocopy .1. legal docunint nriMna name change(Is., manlags certificate,divorcedecree at legal doaanmnt indicatingtelaklngeTa maiden name, etc.)

Ui IWiInot be pmctldng this pmfess!on in PennsylvanIa after the expiration date lnd1ted below and rdqueatInactivesialus. Na fee Is mqulmd. Farm must still be completed — guectlóng answered, mined and dated,

SECTIONA . . •. Please reviewtheccnth,uiñgeducationreqi ntaTpoeteØontheSoqttsweb&le at *Acs.pavfost Clicken GeneralBca,d Inhrmauon. Youare required to retain yourotfldai continuing education ceiffleabe ofcampleflon earned for this Iicanc renewal period until Odobor 31, 2Dl • THEFOLLOWINGQUESTIONS MUSTEE ANSWERED tFyt, ans war yes to quasilous through tZ pnwld. deWis ANDattach a,pln of Th6J *cumiij). IF YOUALREADY jj REPOR’IEDThE INFORMAtiONIt ThEoMDPRIORTOThIS RENEWAL,YOU00 NOTNEEDTOREPORTrr AGPJN. 1. Withthe anØon ofthe one lou am QM iyiwMn9, do yo hoN.orhave you avorheld, a ft is, 4firete, permit,mglsbuUonor otherauthorUon Is piavfln piorecaion onoccupaha Inanystale Wjuda&dlnn7 II yqu leS, plqaie pröIde 01. praltsolon and ifl orjurlsdlctleri 1.1ST: - j 2. llns yow lntst öDllffcn tr lect n,ai, wh!;:vc, Is icier, hovotr had db:!nar, tcon taLon again;t a profsn4on& or oco.etonal Ucense. cectificeca,pennit. regisoeton or oflr authorizationto predict a rmtenlon or ecjpaUon bsJe thycu inany state orpdsdtcticn vrhsve you agited to volflry surrender frilieu of diacJpes7 I -3. Onyou amentiy have any &sdplhiaiy dwsves perWkigsoahist )r wr*essicnielor.oipaknal Icne, certificAte, . permRornmtnIsenystateoeludedktion? 4. SInce you’ Initial appuetion pt last rsnnai, whlebenr Is later, have $‘w withdrawn on appucation for a professional or ocaçatonsl kansa, cflfleste, permit a registration, lied an appUcctiondenIed or refused, or for

• dled3,Inanyreawns agreed not to applyor feca professionalor oJpaUoneI Icense, ceflIfile permit or tagbt&niowysleteortedttion? ry 5. SInce lvw mliii! application or lest macni, whichever is later, have yrnibean corMod (foundguilty,pied gully or pled r.clo itandare), mxlwd probailon’wtievt vaMid or eccetersted rehabilleiva dlsposlioa (ARD),as to any &nlnaI charges,felonyor mdemnor, indu&iganydmg lawstialona? Nela You am Itt NqL’iredIstadose any ARDorother otmind meter thathas beene,g,imgedbycider&a taint 8. Doyw amentiy hevaanyatgnbiaidwgá pen&np and trrçsolved irianysta orIwlsdlran?

•. 7. Since your !uapPaatfewer yaw last rernwd, wMahavsr Is bier. have you bed # DEAm flta dr mvdwd or mfltbd? L smki yaw Weal appheaffanor your last r,mew4 whichever le lair, haveyou bad pro’4dr prM.gn &tie4 revoked,suspendedenrestridadbya MedicalAsdance sgenqi, Mecage, thirdpastypayeror anotherauthqdtq • 9. Theseyour Taitlalapplinilen or your bet nnewal.’whichever Ia bier, hse youhad predict priullege;deiIed, mwoked,suspended, orrestildedW a liosfll or any healui.sere fatally? g yaj irn’Jalapptitlon a yj last ny;), whichever-is later, hew you bian didngee by a hospital, laiivnNy, or research lecatt, with violating research pmbcels, febibing research, or engeging In bther research misconduct? -

tIwuahr.rxas to questonszthro ugh 12,pmvIffe &etoRtANDattach copies of legal document(s). IFYOUALREADY REPORTEDThEINFORMAMONTo ThEBOMU PRIORThThIS RENEWAL,you Do NOTNEEDTOREPORTITAGAIN. It. Since your Initialapplinucn or last renewal, whichever Is later, hive youcngegedInthe lntenperale or habibjal use or a&o of alhoI or ñrcoff, halkidnogwiicsor other drugs or substances that may ImpairJudgmmit or cocidhiaflan? 12. SIngs your initial appilcalion or your Teatrenewal, whichenris bier, have you teen the subject or a dvii maipmcfl lawsuit?Ifyes, please submits copy ofthe entire CMIComplaint,whichmust Includethe filingdale and tin data youware peived.

91 yOUpitvlously reportedthe complaintto the Soard providethe docket number 13. Do oii methlaln azrent medical professional Ilebtiltythewance hi the Canmanweafth of Penrsyinnla? Ii you answer — ‘Not, please providean nplanaVon or reason loran enmpffon requcet

SECtION B —VERIFICAtDNOF INFORMATION

Ived, thatthiseppflcallonIs Inthe originalfomial as suppliedbythe Dcpat,ientof Slats and has not barn altered or othanvisemodifiedhiare’way. I an aqarécf thnaknbtal panauilesfortsmpt,gvdth pjMcrerde oiWormsfjon underlU PaCS.4911.

Lbs I I vefifythat the fliernents In eppflcsflonwe this and coriect to the best or my krn’4edga, Infoonationand bafeL undasmnd that M4se fltanfl en madesuectto the penattos oils PaCE. §49Q4(reisUngto wiswamfaIs!fftbn to ouhodoes)d mayresultInthe wspenslai. restUon ordenialofmylicaice,ruRnafe, pnft or nglstmlioft

Signature of Licensee (Mandatory): Dale: COMMONWEALTHOF PENNSYLVANIA DEPARTMENrCF STATE iaoaa BUREAUOF PRoFESSIONALMD.OCGUPA110NAI.AFFAIRS y 5mm BoAiw or Os’rEOpAmic.MDlctNE

RENEWALAPPLICATION— ACUPUNCTURIST

Full Name RETURNTO;

Street Address Slats Board of Osteopathic Medicine P0 Box S417 City —. State Zip Code Harrisburg, PA 171D54417

EmaIl Address

License Number

Check feppropbta

12 ADDRESSCHANGE— Theeddiese above l.a new address and riot on filewith the board. 0 NAMECHANGE—moname abovelathe airreni name en rhoHcmiano rncerda. Youmust tebmit a photocapyaf a legal document vedf$ng name change (Is, manlene taflificato, divorce decree or eg& docwnant Indicating retaking of a maiden name, etc.)

fl Iwill not to prodicing this pmfssslon InPannayNanlo slier the expiration data Indicatedbelow aridrequest inactive statue, Nofee is required. Form must aWl be con,Iatsd — questions answered, signed and dated.

SECTIONA • Please reviewtherntinuthg educationrequirements postedon theSend’s webeftaat ww,dcs,pe.r!ost 011thon GoneqalOoasd Enfonnedon.YouAssrequiredto retain yoyr officIalconhInuin education certifleatas of completionearned for thTslicense renewal period untilOctoberSI,

• ThE FOLLOWINGQUESTIONSMUSTSE ANSWERED Ifyou answer yes tc questIons 2 through IZ pmride deans ANDafch copies oflegaldocument(s).IFYOUALREADY REPORTEDTHEINFORMATIONTOTHEDOANDPRIORTO tUe RENEWAL,YOUDONUTNEEDTO REPORTrr AGAIN. 1. WIththe exceptionofthe one youare oinunly mnoMng, do you hold, or have youevah&d,h lIcense, certIficate, • permit,regietmifonor other authodnllon to practice a profession or occupatIon Inany staLeorjudsdjcljon? ifyou anaweredyea, please ptovlde Vieprofession and stale orjuriadleflon. LiST: 2. Since your InitialappllcaUo’ or lest renewel,.whicheverIs later, haveyou had disdpllnarj action taken agofnst a pmfessloñal or occupeUonMlicense, certificate, peanit, regialiellonor.’other authothailon to practice a pmft&on or —- oipation issued to you inany stale orjurtsdlcudn or haveyou agreed to voJutlysorrender iniou ofdlsdplne7 3. Doyouwuentiy have any.dtadpilnaiy diames pending agalrst your pmleasbnal or occupational r,cense,certifiedla, pcrmltormglafltionln enystetocrjwicdlction? 4. Shire year ‘laNai application at’ last renewal, whichever Is Iater,-h&e you v,ithdrami an-pUcaUcn (ova pmfossloñel.er ccajpeuonal license, certificate. pennil or reglabellon, had an appilcationdenial or rehise4 or for dfadptnmy seasons agreed net to apply or reeppiy for a professIonal a occupational license, certiflcete, pelinit or regis&aticninany stats orjctsdlction? * 5. Since your initialapplicationor laatrenewai, whichever Is later.haveyou beenocnMded(foundguilty,r4ed guiltyor pied nob nlendem), received probation wtdiout verdict or alemlad reablltflve dispostion (MD), as to any almbal chwg,s, felony or misdemeanor, lndudg,any druglawulalatons? Note:Vauamnotrequired todiadose any — MDorctheratminal matierthathasbean eungedbyorderofarurt 6. Doyoucurrentlyhaveany ahfrl thaTtles pendingandunresolved Inany state orjudedkt3an?

• — 7. Since yovi InitialappUeatlahor your last renewal, whichever Is iét, have you had your DEAreglangon dipled, revokedor msbtdad7 8. RInse your initial eppilcadea or your last renewal, whláhever is later, have you had provIder privilegesdenied, revoked,suspended or msblded bye Metal MsiStenCS aaflcy, Medicare,thkd party paycr anothoraumcrllyl’ 9. SInce your initial application or your last nnewaL whichever Ii later, have you had precllce pMsges denIed, revoked,suspended, or inbicted bye hcsfli orarr healthcare fadlit.? ID. Since your 1nhri application or your iaet renewal, whichever Is later, have youbeen diaiged by a hospital, anivarsily, er researdi Facilityv.4thdofatfngresearch pmtmb, (etailylngresearch, or engagingin other rqseardi mlanduct? C statements Signature SECUONB—VEWFICAUON I sin revocation I Vedtythatthla vedfy aware that of or are olLicensee the the denial . application made cimlnal statements REPbRmD iFjrnsan:wofyosla of subject my 12. It. 13. penalties Urtnso, lb (Mandatory); In flf Ne”, Doy SInce crdhithn? use Stitce and malpmce In to this the ThE the you thodabwuwarusarved. a cattftcala, for OPINFORMATION arlgbioi plies. tiir appUiVon your penalties nainWin abuLe INECRMAnON prvIeuaiyrepwtodtha bmpodnpwlth lawsuit? quasflons Initial Initial plovUs Foqnat of panit wrmnt of &oahcl are appIIUon 15 application as if en or bye 2 yes,,pioao public supplied To inJcd Ihiough mgbbaUon. nplnton or and ThE nar&rl, remrds § or wired BOARD by psofesalonal or complaint 49D4 lZpiDWEâ last to submit your or (reiang renewal, Depflnentof to hatud.nogenlc, InfonnaUcn tenon PRIOR tat the a btha Ilebilty copy detI best renewal, to whichever TO for unswom Ut Board oflhe under of an ThiS hwijance Stale my NP enmption or whichever provide a.llm RENEWAL, 16 knouMede, aUA&h falsifltbn other andluas is PeGS. later, In Civil the dma, copies the request not have Commcrweaith § Is Complaint, docket YOU Infomueffon to 4911. boon Data: later, or DFkga;documsnrfr). au1IdUes) you md,sfans DO altered number have en9aged NOT

aoa which and or NEED tu end at belief. otawise Perrs>1vmO? that In lutist may beat tie TO may result hteitpeiate include REPORT the I IF rhccfled undemtand Irilr YOU subjed In the Pie If ALREADY ITAGMN. Jrdoment you in suspensIon, a tRifle opywày. of that halfl,at a data dull false or I COMMONWEALTHOF PENNSYLVNJIA DEPNITMENTOF STATE i 9.QI9 BuiJ OF PROFES91ONALANDOCCUPATIONALAFFAIRS :jiii1 STATEBOARDOFOSTEOPAfln MEDICINE

RENEWALAPPLICATION— ACUPUNCTURIST

Full Name RETURNTO:

Street Address State Board orOsteopathic Medicine P0 Box 8417 city S14e flp Coda Harrisburg, PA 17105-8417

Email Address

Uteri,. Number

[ick Ifappropriate U ADDRESSCHANGE—Theaddress above Is a now address and not on filewith the board.

U NAMECHANGE—The name above Is the Drnani name on the llcanwre mrds. You must aubetlth photocopy of a legal document vartfyfn9pamecinfl.ianlago tenificate, dIvorce deueeor legal dowmeM IndicatIng retaking of a maiden name, etc.)

U I will not be prodldng this profession InPennsylvania aficrthe e,imllon date Indicated below and request Insc*vs sTatus. Nofee Is required. Fain must aWlb completed — gUestonn answered. signed and dated.

SECtiONA • Pleas. revlswtheconnulngeducallonreQulremnportod en tho Board’swebste at wwt,dos.pa.oayfoct. tick on Gonami Board fribrmaucn. You are required to retain your offlelal continuIng education csfllfioatos of completion earned for thIs Scans. renewal period until October 31, 256 . THEFOLLOWINGQUESTIONSMUSTBE ANSWERED YES NO Ifyou aflntor yes ft quest/ons 2 thmugh 12,pnvwe d& ANDutch copies of Isgal document(s). IF YOUAI.READY REPORTEDThEINFORMA1ION70 THEBOARDPRIORTO THISRENEWAL,YOUDO NOTNEEDTO REPORTtrAaJN. 1. W)ththe exceplion ofthe one you a&bLmemlyrenewing,do you hold,or have you ever held,a tc nsa, dertlllcate, permit,regbtrallon crothor authorSon to practicea professionor occapaffonInonysthie erludsdld!cq? Ilycu anawered yes, please provide the profession and stale orJudsdictlon. U&:______— 2. ‘Slime yale InHIaloppilasfien or bat renonl. whlchanr Is later, have youhad diselpilnaryactiontaken againsta professionalor ocwpotlonal Uwiee, certZcata, permit,reglantan or othe authMntion to predica a profession or ocnipationPawed thyou Insnysbia or)jdsdic&n or have yw agreed to vetuntaiysurrendwh lieuofdbdpbe? 3. Do vi waundy have any &sdpllrry diwgp pending agaInst ynif pofeastonal or oca’patonal floansa, certificate, pemtotitgbtntion Inany state ar)alsd!dlon? 4. SInce your Initial application bat renewaL. v4,!ohever It later, have you withdrawn an appScauon for a professlaiW or opaen& ccanae, x4ficate, permit or reglantlon. had an appibalon donled or refijeed, or For dtd$naiy reasons agreed npt to apply or mapply for a pmras&onal or boflistional Ilcarn, ceftfiae, permit or wgTstadonh myslateofiwledeflon? 5. State your initial application artist renewal, whlchavar laIr, ham 3011bean oarwlcted(bond ufl’, pled guiltyor pled nob centedam), mcdvad probaton without verdict or adoelerated reflabWSvo dposlUoi, (AND),es to any ‘ cAramelthasges, felonyor rntsdemaznr, hdudlr any drug lawvioiaflonsl Note:You am not required to dhedosa any — MDorothercirplnal matterthathasbeanevngedbyorderuFa court 6. Doyouwrrcntty.have any almln cborbes pendIngand Lmresoived Inany state orjwfaction7

• 7. SInce your’InHlaleppllcatlon or your last renewal, whichever I. later, have you had your DEAreglsflhlw, denIed, revokedotnaMded? 8. SInce your Initial application or your last renewal, whichever Ii later, hae you had pivtil at prtl1agas denied, revoked,suspended or reeMoted bye MedicalAssiaffinceagency, Medicare,thirdpwty payer or another authotily? 9. sInce yott Initial aplcatIan or your last renewal, whldinr I. learnt,have you had practice gdvthga denIed, revoked.aapmided, rastided by a hospitalor any health re fadity? ID. Slime your Initial application cc your last renewal, whlchmr Is’later, have you bee., theigad bye hospital, uNvaisUy.or msearth fadtb’ with .1olng roach pmtera, WilMa; research, or engagng In other research mlsndud?

L_ 11you answer yea to quistM ns2thiough 12 nv1s fdUsAWQêtthopies oflegal ddcwnsnt(s). IFYOU.ALREADY •REPDRTEDTN INFORMATIONTOTHEDOARDPRIORTO This RENEWAL.YOUDONDT NEEDTo NtPDRTrTAGNM. 11. SInce your Initialapplicationor bit reniwal.whicteycr is Ist% have you engaged Iii the intempomb or habitual use or abuse of clh& or narwilce, hafludr,oorJ or other drugs or substances.Itat may ImpairJudgment or coordlsiaUon? 5inea your LiNlet applIdon or your last mews!, whfthenr is later, have you been the siitect of a cM m&pa lensil? lips1 please aubmlla copy of the entire CMI Cenpierni, which must Include thefiflna d#t, and the dale i’ w.m ssvsd -

9rycu previously mpoded the complsh* to the bard provide the docket number Do you lnlaIq aiffont medlcd pmfesslonal flstThr Insurance kithe C&nmnnwealthof PnniurIa7 I!you answer .fl0a, pleno provide ah nplanaflon or reason far an enmpfton request

SEC1ION S -VERIFICATIONOF INFORMATION . .

1vadly that tifisapplcdtion h Ulaoriginalfa,mat ssLçfld bytha Department aiState and h notbeab allaad ocothoiisa modliadn anyy. I Bin ayMreotaiá atudnal penaidestrmpeiâig withrjbflc rewMaorflrmalon under t5 Pa.C.5.§ 4911. -

I I • 1vedrythaI the statementsIn this eppifla am ive and coimfl to the hest thy knofldgo.lnnnnauoh and hilleL undoralentiftit ithu

• stalmnenb am made sijb]cd to the penalfes of IS PatS. § 4Th (miMIngto unsv.tm iaIsfflllon baithoflffes) and may rw* In the auçt1&on, revoon orGoni ol my Iios9. c&1ta, pannI or raglsfretn.

Signature of Ucensee (Mandatory): Date: PHYSICIAN ACUPUNCTURIST ÜNEWAL COMMoNwEALThOFPSNSYLvMIA O2Q DEPARTh&JTOflTATh BUREAUOFPROFESSJOMALSlIDOGGUPAUGNAI.AFFAIRS 8Mm BoARDOFOSTEOPAThICMEDICINE

RENEWALAPPLiCATION- ACUPUNCTURIST

FuIINsme .. - RSWRN TO:

ftntMdmn - - •State Board of Osteopathic Medicine PD Box $417 : ,.. -3Ia• tpCode •Kanieburg,PA 17103417 El-an

License Niflr

• Che*ffappraØrI.t. -a ADDRESSCHANGE-U. eddtths above hanow cdnss sidnclü fiadth lbs board.. U RAISEQIANGE-The none aboveIstho.pjn,thimi on the Ucanr, mxr& Youmuit iflmfln photocopy of a kgaI docmnant v.rff)Ingnan. cbingi Qa, maMip ealflcsts,.dlvorce deere. or leant docamwntIndicating.itatng of. maiden rai.,e.J

o IWI riotbe prnctidng this profession In Penns4van1a aftertheeçñljun date hd1Wd kölowand rdquestInactivetata Nfl.. ‘equimi Fañn mat .1Wbe comaletöd —aunllons enewnd, etwiedend dng.

SEC11ONA PICaGOleviewthe ovutetibigeducathnreqt*.n.qti pa.d cmlbs Bqt wahilteItW.IW4OLVa.CCVIQStQkkOflGi0mI Scald bitrmadcn. YOUire mguirsd to ratehiyoureWdal continuingeducationç.rdRntas ofe&pMkn darnedfor this ltaqie zvriewal pododuntil Olotr$1, oPe . - -

• ThEFPLLCWINQQUEWT1ONSMUSTSEANSWERED : . ffü anãers to öäsilons 2 *mugbIZ d..*laIieANDhlacb copies ofk&deamrsn44. IF YOU*LREIDY Li. REPORflOml INFOqMAnQMTOVIEFOARDPRIOR7011115RENEWAL,YOUDON0TNIW 70 ftEPDRTrFFGML . 1. ithe.ptii &thoameu at any do youheld,orhaveyoushwhdd, a !s’inlIIfl .. orw soaOon b pdxarfl, fnWcn a opa h eny athon? Ku riwetadflU sod . s. •••- Wflse ia&lde the.• prñfialar.-• fl* oflcfldtctlon. .— a Sints ItOWInlueläppi1caoii last NfliWflI,WNclevn Wliter, hays youhad dflnajy action ogàbela or ocwptbn& inne. oatMw* pen&Lmctatmlonorothwa*ameei i pobsalonal . jqj gaert anyflte orifldjctlon or haveytu arced vrAry tmeodw LilieuoT&dptwl • -3 Dova athfl hat any dlee4ThiarV&wge. psndb, e(net yourptsfwI arcfcn.I linens., ....l&4a, . -.

I 49Ln In tflIlntIcfl pt last rne..t wlilcb.nr Is Ide. )Ys %vuWth&usti an applä9i ler a - ‘sntnal a otcupatioiid tera SfiaIe, p.mdl a glabadçn, led en eppicabon daijed or Msed; a ta .•• tSs,4aá’y mns arwdfl a fly fan pvfaloral or ocaçflonel acne, cotSfie, pemika —. regitation hisnyale orJtWIcuon? .. • — £ SMaijcwlat& apfluon or hid maiwsi. fllcfmv.r it liter, haveyOU beençcintcted(und gWIbcpiedmilliyor • plededa fli&m). r.cslved.ptcbatioWwthbulverdicta ecasisiatad lehablitefre dusosWon (ARD).ain .r at.affi c a .Wony nj, bxJia&gany thug Ipwvt!flom? Nok You at not ruquliad b sdca wiy AroVWWl2sfrVtdhas basilw,pd byorderofe cofl. •E 7. an n W .ppicon.or vw lOt raniwel, wIir*cvw Is liar, iai’d you had yoiw DEAmsthüa&ndesed, - - . rivdcIdcr.dMaid? . I . L. SIre. pOW iatd apflvan Of )9W lflt ,.,4ivhlth.w, S bier, has )OU hid pIUId pflg.s dsfl5 mvohsd,susöendder rIddfed by. Mi AAhMncs.gäncy. Male, thirdiwly pawsnoUer.utiiciitfi a. sin. yur Inwal ipffaaan or your lairnewal. witinhuve, it Sr. hailyou had papt1a prtdigi arJed . E OtraNded bye hospI1 aranyhdthcar. iecfll iioked. ,uwendtd. 10. Sbcc yew InIUM.ppflcaaoner .ow last renewal, wNthenrIs War, leveyou böen dirged by etnpyaj, • unlflly, or rasbarch.bdlljy iIth iolsting renarcil put..3.. fahl5tng raeetth. or enasoing In bthst rcwth mbcoMuctl - statements cevocaumt Sm

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I COMMONWEALThOFPENNIVLVnaA I) DEPARWSU OF STATE Zuy oaa BUREAUOFPROFESSIOWU.NIDOCCUPATIONALAWPJRS Sr*n BOnD OFOSTEOPAThICMEDICINt

RENEWALAPPLICATION - ACUPUNCTURIST

Full Name RETURNTO:

itrsetkddmse State Board of Osteopathic Medicine PD Box 8417 city State Zip COdÔ Hairlaburg, PA 17105-8417

EmMiAddmss

Unsa Number cb.aucna D ADDRESSCHANGE-mo address above Ian flaweddren ‘rid not en filewiththe ban C MARECHANGE- Theno ebo%’oIstho agiwt name on the taiwre rnt& You must .tthmH a ptctoeeaf a legal doémiiM visitylagnas,. dwngs(La, maflgs teiVllta divorcadean or Is_I docwnnt IndlcaUngcetsUngore maiden sine, eta)

U IwlI not be pmdldng this pioffisslon In Pesineytvanlaafterthe exphuVondetohdatad belowañd taquest Inadive statis. Notes Is inquired.. Form must .1111be camoletsd—puesflons answered. ataned arid dated.

SECTIONA • Pbaoèmiduwthenthxihig edurstidrireqtdlwnerbpasledontheBoard’swelsh atw,n,ioaoaoucot Qldcon Onrel Board Innie*m Yea an raqclred to retain yoyr offidal canUhluihu educationcefllflcalat of completion earned far this license renewal perioduntilOctoberSI, 2O -

• THEFOLLOWINGQUESTIONSMUSTBEANSWERED - MYDUanswerywato Questions 2 Mwugh 13 goWda detailsANDeach coØes of legaldoânneAt(s).IFYOUALREADY REPORTEDThEINFORMA11ONlo INCBOARDPRIORTOfluB RENEWALYOUDONOTtIREDTOREPORTrr AGAIN. 1. Wig,the wan eddie OAtyou em aurerdiyreneekj, doyou hold,or haveyoueverheld, Iccns wflfl pwnfl,,WeUneonor othettw1mta to Waea Spmflin or ccaei Inany aWlsarJwtsdIdon? Wyou answered ts, flies providethe preteeeloflend .a crJhdictJoa

2. Since sw Initial appilnilen as ht nn.fl,-whlclmwe Is later, have you Id dedflqary BCfldltaken against a pMnsiott or oajpeUensl bone, ce4lfl, mglstaUoii tf.othar airncbathn to pcuce a pmfesthä or fl haYS opaUan 1muedtoYOU slits orjc&5on Or U 191ISd to vatbntrny Mm,tideII lieu ofddpine? 3. In DoQU OWP3idYhave any.dtnwI .*rqjta pef tablet your prolsionn3 or otcwe!anaI kne, cetto, . pemillat roatsbs HanJOfi!YJ orjindldon? 4. SInce yoailnW.t app&aUon OFhIt renewal, whkhqnr bIaterrhaa vu v1thdrevman-eppEcetlon for e o4ssleil.cw monW Bone, silflcate, pwft or rbaZcn, had en qplkton dqilad or refusaL or dbdpInis reasons agreed not to apply or respçdytr a pcfeeabaal or eupatiiM Ilceise, carifilaslo, pn or çtsUonInwiysflfl,rtsdcn7 5. SInceyowlawal appiinclkn or mnctinhawal,whichever Is later, have you beai oonVl&ad(foupdgully,pledsuUlyoe plednato contenders),rsàelwd abaUon vAUioutvest or salomta1 *abatIve. disposItion(MD), as to WmIn&charges felonyor mIsdemeanor, Indudthgenydnig lawiddadani? NataiYouam notreQuiredtodiudoseany AcrotharaIminel motterthelbaa beanewunge4byordar ole court — 6. Doyouandy have any atnfrel dmre% perdhig and umascived IAsty slats orJudodlcU%? — 7. md.dorreShin year lMlai appiltetlet or your Jut mnewai.wMthenc is thbr, have you had fl PEA refllbln dq’J4, 8: Shin yew In)JaI .DnUon er.yo* batinnewel, akher is laW, hare you hadpcolder pgendenlsd, - revoked,ascended orreckidad bye Medrel Mslafl tezy, Mdcem, pastypayEror • tfl — P. Slice your Insist appUcauce or your last rennwa witidievir Is later. have you had predice plvQas dorded, zkved. suspaided. orrasbtdad bye hosPai OF8Ii haith re MdNly? — 10. Sb.ce your InIU&appllcetli or yr last yencwal. wNn.nr b later, hnn you bet, diurged by a haIt uN’r&ty, or mid, taSty with vlolailng-reswth ebchi, frW6t,g macarch,or eagoginghi other rwóasdi mlandu - -. -. .- - I Slgnawre jsvocsUon am statements ______

SECTiON I

vwffr’thet

venfy

aware

that

are this

9—

The

the

denial

licensee

made

appibiton

VERJ9CA11ON

ciminai

statements

U9ou HpbR7ED

•

subject

13.

12. It,

penaltIes

añsnt

Pnae,

(Mandatory):

Do ‘ii mØmce sInce and corndlnaUcn?

Sh hi

use

No. to

this the

THE

you

the

you

thtdn

or yes

o&lflcate,

for

a1Tnal plMSD

apicaUnn your

ymir

penawes

maintain

fine INFORMATION pmvlDusiynpenad

tampedng

INFORMATION

lawsuit?

qvntions

Initial

mills!

you

pmyldean

fennel

pennil

wnnt

warn

&mhd

are

with

appksu;n

application

true or

?a.C.$.

2L&ough

ptibila yea,

served,

supplied

hiedlcd

tegbfltion,

nplanWon

ned

ThE

please

the

rnU,

miwds

irect

pr*nlcnal

BOARD cerapleint or

49D4

last

the submit

your

zcvWà

(mlnne

r.aswal,

Depwnent

infdrmadun haiIudnvgeiil

‘neon PRIORI

Eat.

Die

ftabrb’

copy

datuI1AHD

bcst

the

renewal,

whichever

far

unuwom

Doard

wider of

an This

kiarance

State the

nemon

whichever

provide

entire

RENEWAL

knowledge,

.ttha*

faIsffltbn

end other

Pa.C,S.

Iatu.

telnet

Clvii

the

copfrs

the

‘equaL

Ccmmcrmeaflb §

have

Complaint,

dodtenwrbar

YOU

info,maffnn

to 4011.

Date:

been

later.,

auticrillas) of

you

sidmtsns

&te,td

have

en0000d

NCT•NEED

which docwneat(.).

and

or -

you

ci and

belief. otherwise

Penns)4vanIa?

that

trust -

may

been

tie

may

sosuil

Include Intemperate

REPORT j

the

IF IhOHCd

midemtnd

Impafr

tuNed

the

*LA

ITAGAIN. judgment

you

mispensic,n,

fihine

any

ci iAW

that

answer

haUtuai

way.

data

false

dvii

I I I

H COMMONWEALTHOFPE4NSYWANL DEPARTNUIFOPSTATE SunsaJ or PaorEsalOffALMW DccupATlW. AFFAIRS 3uiy I3.O21 STATEBOMP OFOSTEOPATHICMEDICJNE

RENEWALAPPLICATION— ACUPUNCTURIST

FuflName RETURNTO:

Strnt MmUa State $oard o1OsteDpathIcMadlcIno P0 Box $417

City - State ZlpCode Nanlsburgp PA 171054417

Em&iAdthrn

License NülTther

C1s& lLsppmprMs 0 ADDRESSCNNIGE—ml eddrsn above In nmv eddmsa and not en ifiawiththe hoard. NAMECHANQE-Tha nameshovels the amant ,whs ontheitenawe inst. Youinuat subaifta phototapyafi bgar document nd4ing name change (l.a. mwiage ceflhlcata, divorn decratof IaI document Indlaln9 Maidng aft maldenneme,eta)

D IMunot be pmdidng thIs pmfeselon Ii enzlnnla attn the eçlraflon data Indated b&owand request Inarika alalus. NDfee I. requIred. Form must .INI be motsbd — guaettOflBanswered, slned and damp.

SECTION A • Pe m*wthe cqntmtg eduUon requWmcfiWpostedonTheEaaM wthu. at *daaoaao*at. Cidi onGs’iecslOsard IWvanabcr. Ye! ire reqbfredlb Main yoia bifictii cel,ilnWngeducation ceflIftna of taiflejon eaniefltã tine lrcanaerenewal pertedunWOctober3t.2U6.

• THEFflLLOWINGQUEJCtNS MUSTBEANSWERED -

• if youunre*yos to quosdañs 2 hmogh 12,pvwdo detaHsANDsthpi, copies aFkEaI documenq4 IFYOUALREADY REPORTEDWE INFORMA1ONTOWE BOARDPRIORTOiKE RENEWAL,YOUDONOTNEEDTOREPORTrrAGAIN. 1, WIththe na9 VonaTthe OneIOUamäLnrondylC4m’lng.do sea hold,er haveea eV held.a Itrae oerffflta, permitrelstm&n rather euthalzatlonto psoeco. prefasalosioroipetan Inanyatta orJwWdlotlo?Ifyou answeredpa. rkne pmvlde the professionend steWorjqnsdleuan. LIST:______2. Suite put IMtkI ip)caUoa or LastrenewaLWM*IVã It lain, have hid Aled$nwy actiona eInst a picfasl&ialor ocaça5o& tann, ficate. p&mft.reOIcfl&n or ether autharisadbqlà pmtdoe a P%ebi or onon laaatd lovou hi y stele orfrtsdc$onu tan you egreed Iavoluntaryaunendwb,jeuof dbcipThjs 3. Do >ea nentiy have any dsdiwy .I,c. against cw pohzslon& or opaIrl flcon float., - pem,l or regifltion Inwrythte ,, orIwtscIan? 4. three your ffiIaI application or list niiowaLwhtcbner Cl Ialw havoru vdflflwn in pp3n for a : nI,c-flal Utense, cerifitea, pesrnltorthglsbstlon. hod an appflcaVondwiiedor refused,or for dInay ered ret IDapply c mapply fot a pmfos&orreIor sipeloqrelkenee, cetHIla, pennII or teglfllont’z.nyitelaorjurtetx?ra 6. Sky your life! eppwcaffenathat renewal,wflchover kin, hive youbaei tmlctrJ (faradgWly,$ad gullyor pled cola ntcdsre),.mvid probationwithoutva-did or ascetemted rahabilteWadlo,W&i (ARD as to any crimlnsdiartee, frknyormeinorc, IndudinganyE lawblolsUona?Note:Youare net required to dcdnaa my Alt orothnratmTnal malterthethas bar eçung byordorofa oaurt U. DoyouwnrUflave any otilnel chargonpsidingantiwlrnotyál Inany steta &Jw&sti 7. SInceyotilnhUel application or your lies renewal, whIchever is lust, have youhod ‘wr DEAm,ThItei1 denied, rwgdwda 5. Sin. yow.lsIuaI ippnãuon Cr your last nnmsw!. whlohenr I. later, have vu had provtder psMIees denied. revthad,suspendedor lztdodbys MeAaIatenee agen, Mem, Thirdpi$ pain anothersflorttv? a. Soc. —lariatappflcetlcn oe pit list mn.nL wftkh.nr It kite, ban eu hod p’ata fltleges doMed,’ revekid, smpendid,ar mslnded by .hfll orry htUth cam hdlty7 ID. Shin year Iniftal epplicales or yaw let renewaL fllc*tpnr It later, havi you been chased bye hoapiki, rivesaJtr, or meeezth fedtly %lthtelatng ronaareltprctI., faWng research, or .nu9Irc In ether ritasruli CTWIdLIot? Signature

stgtemene revoUon 1

SECTiON I

ndfy

verify

swsradtho

that

or&nlutotny

are this

B—VERIFECA11ONOF.iNFONMATIQN

the

Licensee

made

wiminal stetemen

RfrORTED

lffei

you

sit]

13. 12.

penalties

answer

is (Mandatbry):

and Do SInce No’, mâlpmtha use coordinaucri? Since

to ‘lf

fla

his

you

the

you

The

yes

aatfiate.

furWmpedn

original

pease

ybur appncation

yew

pgnWVes

maIntain

abuse

pcthlolJiIy

INPORMAVON

.lata

quasiloos lawsuit?

inhiel

initial

vo.,

pmvldiah

Foitnat

pennlLarresbäVan.

of asna-i

worn

alcohol

are

with

appirastion

taporled 16

apilcaVon

usupp1iod

Ifyap,

bueendccnict

Pa.CS.

pubUc

semi

midlc&

fIfluh

exlanatlan

ThE

plosso

ihe

nsrcocs,

rswrds .

or -

by professional bOARb

4904 complairñ or

last

the

submite

sour .

pmvWe

orlnfwnieUon

(mIaUn

rauwal,

bcpoztsnent

M&icnogsnI

reason PRIOR

last

flthMy

copy

detáiIsANI

best$

the

ft ranewat,

wNch.nr TO

icr

unawvm

Bard

under

Thi5

bsurrnn

State tbeantire

inykdofldae.S*mwtob

enmpflon

whichever ..

pmvide

tNEWAL,

fabJntn

and oter

Wth Pt.C,S.

iMm

has

Civil

the

dwgs

tha copies

request

not

Câmnomveaith

§4911, have

Complaint dacket

YOU

Date: bosh

a ktir, .

au*tvriues)

yvuengage

siibstances.thai

DO.NQT

Iegai -

effoad

number

have

document(s). which

and

oretheiwlea

and

of you NEED

befet -

Pinvsnia1

must

may

beeti

the

may

result

htnpomte

includá

REPO

the

módifled

widcmtsnd

Impair

YOU

suled

the

If the

ALREADY

ITAGAJN. Jud9ment

you

suspension.’

fi!nnk

any

thut

answer.

habiwal

way.

lse

oMI

I RESPIRATORY TH KRAPJST RENEWAL COMMONWEQ.ThOFPENNSVLYANIA oaO’ DEPMWE1tF OF STATE BUREAUor PRorgEsiowN. MD OGCUPAT1DfWLArrpJgs STATEBOARDOFOSTEoPAThICMEDICINE

ReNEWALAflLICATION— RESPIRATORYThERAPIST

FuliNeme RETURNTO: State Board of OSteopathic SheetAddmss Medicine PGBox 8417 Harrisburg, PA 11105-8417 - City State Zip Cads

Email Mdmas

Ucenas Number / Cbodfleppmpdàte

b ADDRESSCHANGE—Thead&ass above Ice new eddm.. and noton filewith the Doard

O NAMECHANGE-Thename above is not the cirrantname notheIcansummeat Yadnuiisubnth a photocopy Ma legal documut vcrlflng an chanGe(I.., marriagecerUnen, dlvor decree or leaI documnt indicatbigretakln Ma maidenharna, tc.) I O twillnotbe pructidn9thisprclesaionInPenralvanla after the eçiimUai date lMR.ied belowand requestThxUvëstatis. NDfee is required, Form must still be completed — cubsta answered, signed and datad.

SECTIONA Please reidewthenVrwlng educationrnqulminits postedonthe Bowd%wabsfleat CkAon GnmI Hoard lhiothiaton. Youeraraqidredto retain your officialcontinuingeducation certificatesof comØalan earned ftr this licenserenewal periodOntiIGabber 31,2O

ThEFOLLOWINGQUESTIONSMUST•BEANSWEREU

V[S l’lQ Itj.vu unswacyes Ia quasilon 2 mmugh12,paId. dsteHsANOat$obaos &kgeIdowMgwn(.IFYOUALREADY REPORTEDTHEINFORMATIONTOTHEBOASWPhIORTOINS RENEWAL,YOUDONOTNEEDTOREPORTITAGAIN. ‘1. th theexceptionelSie oneyouemointay renwjng,do yi held,orhave youeverheW,Slicense,certflrate,permit reglsfrdonorothereuthothaffonto pmWcaapmlenlah or oipan in any state arjiktedxon? IIyou answered ales, please provide the pMeealon end !tsIo crjuritdicuon. - UST t Shies yaw Initialapplicatiod or bet renawal, vihidiever is liter, have you hid dbllnàq action‘taken againsti ‘‘ pmiossionai or ccospatianallicensa, certificate,permit ralcfltion oFother authodntn to ac1les a professionor — ocoipalton kried,to yet, hi anystate orlisladictiocor haveyouagreedCa‘evlunffiiymmends-lpBesot dlsd14hie7

• 3. Doyou cwrentiyhüve any dlsdpilnai cherve pendingagainstyour pmfes&onaior OXrJpSUoneIilcenep, çartiftthte, . pesmhtcFreaIabaffoninanyamteerjuItadon? 4,’ SInceyour Initialapplication or last renawel,whichever lblater,have youwithdrawnenapflcadbntorn prebsalonel . oroccupationalUcanse.certficate,permitOrreglebeudn,had en epc$ó deniedorMused. otter disdüiary reuscria weed notto appWor ma fora pmfa&onalor ocoupatioralleans., ctflcab, permitor reglsfradonhi any alas or ‘ ludsdlcUon? ‘ 5. 5inceyout Initialapplication or rntsenewal, whIcheverIi later, haveyoubeen eanlcted (foundguilty,pleduUiy a . Sdndio nonlandem),receivedprnbetinnwithoutveñilclor arxeiwatddrehaUffiffvedpc&tn (MD?.as to any orbital therge telnet mffidemesrcr,kdudinp any druglawWointiohe?Note:Youereiwt requiredS dmdosa any PROär — otwolmlnamcltarthathasbeenãp4mgedbyotderolAwuzt C. Doyouwrrenftyleve anyrsbiibialdiergea pendingandunresciredinanyslate orJudsdb5cnl

. 7. Sinceyour Initial application or yaw last renáwal,whichever Is later, have you hod yaw DEAsegisátion denied, .. revokedarrasifided? S. lines your tiiu& applicatIon or your lest renewal, whichever I. later, have you had pm’,lderprivilegesdenied, — revoked,mmpcndedor resbicted by a MedcelAssistanceagency,Medicare.WJdpe’ payu oranotheraliloilty?

I you answer yes to quasilans 2 Unuph 12. provIde dpMM,AND ett*th copies of hgai docwnanffs). IF YOUALREADY pJHE INFORMATIONTO.ThEBOARD.PRlORi0 ThlS.RENEWAk.YOUDONOT NEEDTO REPP&ITAGAJN. Shico your laWol ppUcUon or your bat ran,wal, whichever is later, have you Sad prucflse pMeges denied, revoked, auspended, or restfded bye hospi oranv health re bdlfy? ID. Sinceycurlnwal appllcálon oryovr last renewal,Whkhsvnls talc, have you Deal thaied by a MiflI, unkeisity, — orresearchfai’ withviolathigreseardi proto1a, laiaIMngresearch,oreflga*lg in otherresearchmIaiduct7 it Shies your initial appUcefton or last renewal, whichever Is Ialer have you engaged in the Intenipsate of habitual use orobuse olakthoi ornarcott, helIudnogerd or other dms ors’sthncen that nay bipatr udgmanIa coordkiaon? 12. Since your initial eppilcaflon or your last renewal, whichever Is later, haveyoubeen the sueot of a clviimalpmttkè lawsuit? If yea. please submit a copy af the entire Clvii Complaint which mLm(include the fihIrmdab and Iha data )2!L!!rw served. fyoupravIoaalyiepoqied Via complaint to the Board prtvlda the docket number 13. Have you metycur nUmlng educationreq rern?

SECTIONS-VERIHCA1TON OF INFORMATION

aharadorotherwlsomodWsdhanywuy. I Ivarl’thatthIseppliftonb i theotmbalIplmateSsuppfledbyvepepartnentoistatewidhasrntboon am awn ofthe ntmlnai pniiles forIanwwThgsWipubic records or lMonnetionunder 18 Pa-CS. §41t.

Informafloii baileL I I vedfr thai the statements in this epItm we hue and rrecl to the-best at my lalowledge. aM undwsland that fse statewenb are made subject to Vie pemuiies oilS Pa-CS. 4904 (raIdingto wiswom falsitatton to authoritIes)and nay resvlt Inthe suspension, revocationordflal of mylicunse. cartIflcate pennit or reiaftuaon.

Slgnabsreofucenses (Mandatorvi: Data:

2 COMMONWEALThQI PENNSYLVANiA .OEPM WOW OF5Mm Zty I BUREAUOP PROFESSIORALANDOCCUPATiONALAFFØJRS STATEBoARDOPOSTEOPAThICMEDICINE

RENEWALAPPLICATION- RESPIRATORYTHERAPIST

Full Name RETURNTO:

State Board of Osteopathic Sbet Address Medicine P0 Box 9417 Hanisbwg,PA 17105-8417 City State Zip Coda

mien Additsa

License Number

Check ifeppmpdat,

CI ADDRESSCHANGE- The address-above Is a new addraàs and not on ID. with His Board

CI NAMECHANGE—Thename above is nbt the current name on the Etnsursrsxrds. You muat submit a photecopyof a legal document vsrlMng name change (to., marriago cvniflcato, dIvorce dogma or legal document IndIcating ratoking or a maiden name, mcj

Cl I wiUnot be.pmcUthigthis pmffiesian InPennsylvaniaafter the eplralron date Indicatedbelowand muest Insajve elates,

• NoTaoTarequIred. Eonn must still be completed — questions answemd. sTartedand dated.

SEC11ONA - a Please reilew the onUnuffi education requlramente posted onthe floarfl he-at w3eaca.aovThzt Cid(cn Gonnl So&d Information, -Youart required o robin yarn offjoel gonllnWng eduUon certificates of cemplatlan earned for (tile Ilcarwe renewal period until Cetebar 31,-a’i2038,

. ThE FOLLOWINGQUESI1ONSMUSTBEANSWERED - , i4u anser yes to questions through fl providedeteRs ANDailacheepln of legal document(s). IFYouALREADY REPORTEDTHEINFORMATIONTO THEPOAROPRIORTOThIS RENEWAL,YOU 130NOTNEED10 REPORTITAGAJN. 1. Wth VieeepVod oft,. cUeyouare cnndyreneaç, do you hold,or have you everlletd,a icarsa, cmlflcate, panalt, reg!sfltion or othorauthortIon to pracSca a prdsssbi npa&n Inany elate ujwlsdlaor? Ifyou anrwsmd y, pbas.L______provide the prafss&cn and staTs of li.tsdlcilna. 2. SIne your initial epplnaflon or last renewal, wtlchenr Islam, hav, you haddis4flng!y action taken eflt a prnlmrnl or ccipforial Ilcaiae, açffrato, permit reglsbaori or other suthorha&n Is prectice,a wofesalon or or,plon Issued to youIn eny slate br)tsflsston or have you aGreed to Wlunterysunwtderin Vailoldladpfl? 3. Cc you ojnan(y have any dlsdpllnary diaiee ptndD’ agethat >tt#.pmras&aial or ocaup&naj cwisa, catttcate, pnnorrbbaronthanyaatncrJudsdic1ca7 —______4. Sinceyaw InItial application a lent renewal, wbldiewçr Is lalar, have w wilMrawnan epilca&n fore ptofslonal croaaJpatiaial tense, certificate, pemdtu rrm1on. bader, spplifln derded orrehmed, crbr esdptiey reasons egrend not to apØyor rpply ‘prthsalwi&a’ eUon& Icense, certificate,pfller regafratonInany ale cc JLDIsdICtiU1? - 5, SInceyour Initial applIcatIon or last i.noW&, whichever Is later, hive you be convicted(bmd 9L1i4’,pied gully a plednob entendem), reedved ptvhadon wtzut va*i orenlereted rdietflratve dispeto (ARO),as to any almnl dr, felony CrmIada,iaw, fri*dina sq drug lawvlela&ns? Noter You era not reqund WM*se sq MD or otheralminal mater twt has been epung.d byorder ofa ewt 6. Cemu ameflly have artyuti,k charges pendingend tmrndved Iriany elsIe aJudex?

7. SInce your Initial application or your last renewal, whichever Is later, have you had yourDEAregIbsUon dmlcd, ravekoda B, Since your InItial application at your Mt renewal, whIchever Is bier, have you had provIderprMleges denTed. — ranked, stependad orreebicted bye MedicalAstetence agency.Msdinm, Hi1 rot aotherauthodIy7

I if you answer yes to quetiona 2 ib,tugh 12. pmvido UflalisAND .16th copies of legal document(s). IF YOUALREADY REPORTEDThE INFORMATIONTOThE BOARDPRIORTOThIS RENEWAL,YOUDO NOT NEEDTOREPORTrT AGAIN. 9. Since your hillel application or your last renewal, whichever Is later, have you had presto pdvees denied, rovokod,suspended, or restilded by a hospll or any health re ladity? 10. Since your Initialapplication or your last rinewil, whichever Is lator, have you been c)iorpedbye Irneptial,university, — a FORethffiWüy withyfling rcseatdi protocols.fsifytng N59ar, U eiiflig Inothe rnaamh mtoox&tt? 11. SLncaiour Initialepp4lcaUonor Fat renewal, whichever ISlater, have you engaged Inthefrdemperalea habitualuse attn ofalcohol or narcoba, haiudi,gecfts oroIler drugsorstthslancn hat may hepak Judgmenta cacidlafl,ni 12. SInce yourInifisi application or your last renewal.whkhevsr Iaratsrjmw youbeen (haaubjedof a dvi malpractice lawsuit? Vye., please submit a copy ci the entire CMI Complaint whIch must Includ, the filing deWand the data yea were served. -

— “I! youpmvlouslympoded the complaintto the Board provide lb. docket number 13 HeveyoumctyourcUnuIngunationroqubsmen? - -

SECTIONB - VERIFICATION OPINFORMATiON

I1smhfythat thIs applceflcn bIn thaoil;inoiformat as suppted by the DepartDentof Slateandhoa notbean &Lejtdoromwtaa mMl%d hmiyway. I am swore of the cflmlnelponaitiesforrrpe1ng withpubkrscoids crlnoneatIw LmeF lB PflS. 64911.

I verifythat the olatailenta bi tflc appueaton ore tue and ounect ic the best of my knowledge, lMonnabon and belief. I undemtand that false statements are made subj to the penalties at 18 PatS. 4904 (mIatno to unawomfdsftcaEoa to etithortUas)and may result b the euspenslon, revocaffonordedal of my iconso, cerhflcai permit qrroglsfrstlcn.

SIgnatim of Uieee (Mandatory): Deja;______

r$.&ft 1,..ekcJfl.W %*jsjr I ?“ k tR CnCINGtUi1EXPrnEb!acENSE MJaR SUtT.ILIbISQIPUNW?4pIONSND’ADDIlJONAtIIONETARY. PENAI4mfr” -

2 COMMONWEALThCFPENNSYLVANIA DEPAAWEWrOPSTATE cJtiy11Oa BUREAUOFPROFESSIONALMIDOCCUPA11OI4ALAPFMRS STATEBOARDOPOSTEOPAThICMEDICINE

RENEWALAPPLICATiON- RESPIRATORYThERAPIST

FuJiName RETVRNit: State Board of Oawopaffifc Medicine Street Mdnss P0 Box 5417 Harrlsbur, PA 17105-8417 City Stete Zip Cod.

Email Address

LIcensE Number

• Check Ifappropriate

• In ADORESSCHANGE—Th.eddmis thaws Is a flawaddress end nd on tUewiththe Board a. a NAMECHANGE—ThenameaboveFenv(the inent name on theUeemwrereads. Youmust .ubnUt a photocopy ala legal documSnt ved5(noname chaage (I.e.,maMae certIficate,divorcedecree or leeaIdocument Indicatingmtsldnb of a maiden name,et.)

Iv.flJnotbopmaffIngOhsplotessionInPernlwarie aW the expbtlm data kid1tedbelfrw end requesthodve etete. Nofoe Isrequired. Faini muMGWIbe completed — puasffoçts answered, slân.d and dad.

SECflONA - • PIesC rm,Ie.ython*iubg edudon mquImmen postedon11*Board’swebalteatIAmeAotsaedosL CIh*an GeneralBoard infontafion. Youarerequired to retain your.ofilclalnastfnuhig education cerflfieatn &cempleuon earned forthis Jeonso renewal period wiWOctoberZl,20%

. ThEFOLLOWINGQUESTiONSMUSTBEANSWEREp YES Ifyou anwvyn to qununas 2 HisoeØ f ptovWeâfls ANDatfath copies of legal doathpenf(4. IFYOUALREADY REPORThDTim iNFORMATiONTOTHEDOARDPRIORTOThis RENEWAL,YOUDONOTNEEDTOREPORTiTAGNN. 1. WththectpUon oFthe onej are c*rtiy mnâw.g, doyou hold,or have.youeverh&d,sitcensa, cerVfits, pam!!, raglebedonrather authbdmffonta pradleda professionor oraaUon hiany able orJwledoon? Ifyouansweredyes. pleas proside the profsnlonand state or Jitedlcton. US — 2. Jlnca your Initial application a bat nnswsl whichever is bier, haveyouhad dicdplfnaryactionlakenagainsta . pmfrnloredor ecoupadonalIlcanso,caVflcte. peanUtmeüntJdn or othw aItwUon te fldtce a professionor ocoipaton Jawed to you in anyaWe orjwlscticn orhaveyouagreed to voluntarysurranderhiUguofdscØflne7 — 3. Doyou cwmntiy have any dledplthsiy charges paridag against your profesekxni or ocoqiationai lIcense. cwtifioate pennitoriegietadonInany etata.orJiutsdlon? - 4. SInceyour Initialapplication or lest renew&, whichever I. Icier, haveyouwithdrawnan app&atlonfora pmfessb-isl or oceupelitmaiUcersa,cetflcata, peanUtor reglaba*n, had an appOUon deniedorrefined,or fordletipibiaryreasons agreed rot to aply or mapplyfora prefessiormior oeaapaffni Ucaise, cert&wte,peimftor regisbation anyaWe or fr’sdlathn7 a 0cm your Initial application or lest renewal,wiikhewr Is War, lava you been convicted(founduuflty,pledgullWor . pledrole contendere),ruceNedprobationWthoutveidotcrecceWfld rehaNstaliveasposIon (MD),as toanyufmThal charges, felony or miodemeena, indudhig any dmglawviola6ona? Note:You am nat requt’edto dlsdeco any MD or ‘ otherratmlrmtmoffarthathas beenwçunged byordeofa court 5. Doyoucunwffy have any ahnrildiamas pendingand unmiolvedInanyeWeOrJWtsdIctIonl

7. SInceyory InItial appileationor your bat miseni, whkhevar Is lgWr have you had stur PEAregbfluoaidenied. revokedormatlotad? B. Since yourInitial applIcation or your bet rennet, whichever Ii later, have you had wnhfd!rdWeges danled, invoked.eu.pmidedorresticted bya Meca1 AssIstanceagency,Medicare,fled pertypsyororsiotier authority?

1 1 ‘ if you answer yea to quastonx 2 through 12, roW details AND edac copMs of MW &cumint(4 iF YOUALRLWY REPORTEDTHEINFORMATIONTOThE BDAR0PRJORTOThIS RENEWAL,.YOUDOWDYNEEDTO:REPDRTif P.0MW. 9. Slnca yew InIdal.sppflcsuon or your last iwiwal, whlahewr Ii later, have you tmd pmcdce privileges denied. revoked,suspended,crrest1& bye boJlal crany heth wèbcstyl• . - whiaheverId you bean thwged by a untvcrsfly. 10. orSInceyoijr Initialapplication or your last rnnt later, lve hosØ raseerdi fadItyw4th‘Aolaffngrniarth potocols,f&stfy!i mswdl, orennlnfj Inotherrnsrch mlsxnductv 11. Slice your InlUa1sppllflon or last rsnswal,whkhevar Is Istar havoyouengaod in theWeñiporte erhabilualuse — or abuse ofaloud or nn, haihjckia9edcscrothprdmg orsubslzaceathat maybnp&rludnent oronNnadon? • 12. Bless your Initialuppflcatlonor your last iwnewal,whicheverIs later, hava)w been thesubjectala evilmalpractice dew ‘ Lawsuit?Ifpa. please submits copy cite enthwCNNComplaint whIchmust Include the Blind and the data vopwmoearwd. - — .9f you rWct* reported the complaintto theBoard provide the docket number • 13. Haveyoumelyourctinflnukigeducalkçiraqulrenenb?

SECTION5—VERIFICATiONOFINFORMATION lvUsLthIsapulcatonlaki thoodndtnfl edbytheDeparftenülsbtaand Mcnotb800akaredorcthawsernodlfledlnan,wsy. I am awn ofthecatrilnalpesities forffimpatigwithpubicrearda or bbnaundw 18PaCS. 4911,

knowladga;infonustlon ballet I j verilythat the statementsInthis cppIcaon cm flu, and nect to die best of my and undsflnd thatmice aWornuita cii made subjactto the penalos of 18 Pa,C.S. 4904 (rolitha to vnswom falslflcàtlonto auSindlies) end may result i the aispanslap, rovocaffonor danielofmyliesnse certIficate,permilor leflif

Slunatureof Licensee(Mandatory):

2 AThLETiC

TRAINER

RENEWAL COMMONWEALTHOPPENNSYLVANIA DEPARTMENTOp STATE BUREAUOFPROFESSIONALANDOOGUPAVQNM.AFFAIRS oao 5Mm BOARDOFOSTEOPATHICMEDICINE

RENEWAL APPLICATION — ATHLETIC TRAINER

RETURNto: SlateBoarda! Osteopathic Medicine Steet Addreas PD box 9417 Hairiaburg,PA 17105-8417 City Slate LpCode

Email Address

Uci nBeNambe r

Check ITapprepdata

0 ADDRESSCHq4GE -The ndthosa above Isa now address and not on filewiththe Board

C NAMECIW1GE -The aNna above knot tha ccnaitnme ontheflcaisure records. You mutt mibrefta phobccpy eta legaldocument verH)lng nan change (La, mantage certificate, divac decree or legal documentIndicating nbklng at a maiden lane, etc.)

C Iw43net be prcung this prnfasslonInPms)4vanla aftor the epIradcn dalibidicated belowand requesthiadve thh,it Nolee Is required. Fonn must still ba thmplatad —siestlons pnawerud, cloned and dated.

SECTiONA S Massere’&w tie o,ntim4ngeductoi mqrikementoposted onthe Doareswebe at www.d.pa.wdoet diFd on Gcuifl Board bkrmallon. Youw. required to retain vw omclal conlllmuIhneducA&r certificates of cmnWrlan sarndkr tIe lIcense renewal period 1mWDecember31, 20S -

a THEFOLLOWiNGQUESTIONSMUSTBEANSWERED 14t&i EflSWVflSiO untJOas 2 though 12, pmWd. details ANDattach copies of1a1 dowmenfl). cn’ou REPORTEDThE INFORMATIONTOTHEBOARDPRIORTOTHISRENEWALYOUDONOTNEEDTOREPORTITAGAIN. • 1. WIththe pon ofthe nyi am currently ranme1ng,do you hold,orhave you yahetd. a rfJJe, pemift re*ntIon or oth&mj,amnfla, to precilce a pmfesdoi oronpation in ely state 1 fldsdlcffon? Itou answered yos. please provide the wofesslon and stale orjurkdlctlon. UST: 2. SInce your Initialop$lceflan or last renewal, whichever Is Inter. hove you hid dhtdpwy ecton taken aakid a professionalor occupetiai&license, ceficete, pesnft, restmUi or.Xier euthodalon to pmdke a poflon or acaipaUonIssuedtoyouhianyate oflnlsttion or haveyouwood voluntarys’mndar hiteu ofdkdplbe7 3. Doyou cunenfly have any dlsd&biarythaies pendingagainstyour professional or ocwpadonsi ficsnsa, canhtIo pemit or zsafsfldon Inany slats or juisdicton? • 4. SInceyos InItialppQcaUortor lest renewal;whicheverIs later,haveWWthdrawn an application tort pmlosbial or occupalbial tense. certl it, pennIl or rs*batlon, hadel çpPcaticn denied or rthsiel, or fordicdpllnasymacens . agreed notto applyormapplyfora pm%siooal DroccqaUorialUceree,cartlirete, pennflor reglantion hiany state or judsatcilon? 5. SInce your InitialeppllcaUona bat renewal,whicheverIs later, have you bean cerMctad (found uIIty, pled gufltyor i3ednolo.xnlendere),mtthed pmbauonwithoutvudlctoracoelBial&mliabiltahe Sposiflon (AnD),as teenyatminal charges,felonyor miadenianur,lndudlngartydwo lawt4olations7Note:Youm not ruIred to dkaosa artyARDor — othoruriminalmattarifethasbeen eung by omorofa wwt B. Doyduatnurtly haveanyaimlnalcharges pendingend unresolvedinanystateorludsdtntin?

7. SInceyour Inwelappllcaffon or your last renewal, whicheverIs etar, haveyouhodyourDEAreoTebutiondonlad, revokedormebtded?. 5. SInce your must application or your last renewal. whichever Is later, have you led provider prMeges denied, — revoked,suspended ocresbictad by a MedicalAssistance agency, Medicare,did partypayorCranotherauthodw? 9. Stha your InItial appllasUori or your bat renewal, whlthsvsz Is later, have you had practl piMleges denial, — resoked, suspended, or resticted bya hoepltaloranyhaafthcare ladlityt I ffybu’ansvnryn to quesl!ons2 turnugh i, lawwidsftataiItAWDátfi&,copies ofleg&document(s).IFYOUALREADY REP.ORTEDThE INFORMATIONTOTHE BOARDPRIORTO THiSRENEWAL,YOUDONOTNEEDTOREPORT ITAGAiN. IL Singe your Initial appilcdon or your last meowal, whichever Is iabr. have you betñ dimed by a hospital, univaitily. crmseard, fadNlyWth 1aiaffng canard’ protocols.faIfØg researdi, & engagingI, aherresaardi mfsndu1 11. SInce your Initial application or be! renewal, whichever Is later, hive you era9ed In the thtampwaw orjithffini iso — orebusa ofairiolor r.arrctka, rcgudce orothr dnjs oreabsttces thatmay hnp* Wdgmant& crrrdnaDon? 12. Shies your Initial application or your Ian renewal, whichever Ia bier, have you been the abject of a dv macactIco lawsuit? Ifyes, plane submit a copy or the entire Clvii Complaint which must include the Wino dote and the dais YOUWfl Rfled,

— lfyoupreviouslyrepoflsd the wmplelntlo the Brd o.ida the dcohs* numh 13. Doyou hold cwrent cotcelonvdth theBooMnICorVfiton (BOG)fcrAltdeiloTn!nem? f

SECTIONB —VERIFICATIONOF INFORMATION

IywilyUiattile apcitcauonIs in meoriginalformatas supptodbythaDepaflmetof State and ha, not been altered orotharwl modtllei hi any Way.I am awwo at the t,imin&penaldeafor tamperingwithpuhlIcreide ortnformaffcnund& 18 Pa.C.S. 4911.

I vat that the statements in thFsapplication are true end ixnci to the hest of my knowledge. informauonand bairn!. I undemtand that relay statements are made sttled to the penalties of lB Po.C.S. §4904 (relatng to unsvom Ieislficauonto authorities)end may reault In the suspension, revocationordailat of mjllconsecofllftcate, permit or regsfleon.

Stgnabr ofUcaneec(Mandatory):______PaLe..

2 F

COMMONWEALTHOFPENNSYLVANIA DEPARTMENTOFSTATE BUREAU6F PROFESSIONALMD OCCUPATIONALAFFAIRS st y. STATEBOARDOFOSTEOPAThICMEDICINE

RENEWALAPPLICATION— ATHLETICTRAINER

Name RETURN 10: FuN - StateBoard of Oitéopath!c Medicine Strut Address PD Box 8417 Harrisburg, PA 17105-8417 City Ibis EpCode

Email Address

License Number-

Check Ifappropriate

P ADDRESSCHANGE-Theaddress above Isa new eddrese and not ontilewIth to Bawd

0 NAMECHMGE The name ab&o notthe wrrmtnwne anthe flcenwn rooMs. You must sstxñIl i photocopyofa legal doariant verifying name change (It, msnlag. certiuicelo. divorce dane or legal document Indicating retaking ala maiden name,etc.) I

0 Iwinnotbe pracactngthispMessicn InPenns$vents allot lila apiratlon dole indicelodbelowend request InactiveeWs. - Nofea Is required. Penn must still be corripletod— puestjon answered, signed and dated.

‘SECTIONA ‘ - - • Pleesereviewthemntüiuing edLicetlon ruIremfl postedonthe Bàard’swebsifa at wMv.dcspa.dovk I. OIdconGenwal.Soard Infoonalion. You are required to alan yaw official continuIng eduodtonaatl*cate dccmplelion earned for this license renewal periodunlilDmtsn*èr 31,20& aq •. THEFOLLOWiNGQUESTIONSMUSTBEANSWERED . Wyeu .nsu..ryn to quesons 1 thxoc,yh12,povfdu UflNs A a2&ch copies oliegafdotument(4 IFYOUAl.READY REPORTEDThEINFORMATIONTo ThE BOARDPRIORTOTin RENEWALYOUDO NOTNEEDTOREPORT ITASAIN. a 1. Withthe excep&ci of the one you are ounmuymiiswlng thyou held, orhae you eveth&d, a Ilconso,certificate, knIt , mØshadon ct othar oucclnlSon to pudce a piqienlon or ojped n hiiy ate orJo on? if you answered yas, picaso roWde the prolenim, end ibis orJLwtedkiIal.

. USTr - — 2. SInce yaw Initial .ppucauón or hit itnew&, wMclmver Is Idler. have you li& dbdpino’y aion bkcn ahist a oupeUoñeI ceilitcato, perntiL regbfltlon or othor ft pmcffce.a profession or ocwpflonrcfessImlWor Iise. aitfln ksued ft youkicityeWEsorJwkdidir arliave youagrted ft volwtaq S1flidarki ieu of disolpone?

• 3. Doou cwrentbr have any éSdpVflLy cIlar9ss pàidtg against your professional or a&tipalional ilnse, certificate, pmmhorre.flbiInanysIalaorJudidldn7 4. Sltidé your Initial áppllcatlon or Jest mh.wai,whichaver It bier, hdvflou nlthdiawnan applcaflotkra professional or ospaUaneI icaiisq, catflcete, pennftor roclentlon. had an ñppRcaton denIedor re*jsed, qr for sdpflrwry reasons —•agreed nOt ft eiy or reepplyfora professionalor a athnat iceMa, caruficeta,peasE or regtstralion many state or 5. Since your law.? applIcation or In? renewal, whlciienr Is later, have you ban cenvicted(foundguilty,pledgurtyor plednob onntaidn), received probationwltioi4 vardlobor acederated rehabliltatWedlspoatifonCARD),as toany almin& dias, ftlonyor misdemeanor,Indudnganydruglawvtolatlons7Note:Youare not requIredft dlsdose any ARDor otheralmlnt maftarthathas ban uçunged byorderate ceud. - 0. bayou wrreaffy hove anyci mine clisrees pendingend unroscivd hi any slate orjurhdldion?

7. SInce yaw inlifol application or your lest renewal, -whichever I. later. han you had your DEAreglskoffàn denied,

regokedorreabicted? . . - a. Sines yaw InitialapplIcation a your bat renewatwhlcbever Is later, have you had pra’øldérpdvlees deNted, — revoked.suspended or reatitated bya MedicalAesisterice agency. Medicare,thirdpertypsyoror another authority? 9. SInce your Initial application ár yaw last renewel, whichever Is latex, have you had practice prtliegea denied,

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I ____

COMMoNWEALThOP PENNSYLVANIA DEPARWENTOFSTATh BuRu OFPRØFESBIONALANDOCCUPATIONALAFMRS STATEBOARDCF OSTEOPAThIC MEDICINE JLily 1 aoaq - RENEWALAPPLICATION— ATHLETICTRAiNER

FullName RETURNTO:

State Board of Osteopathic Medicine Street Address PD Box 8417. Harrisburg;PA 17105-8411 city Slat. - Pip Cad.

Email Address

license Number

Check if appmpdab

CI ADDRESSCHANGE—Theaddreea above Isa new address anrinot on tOowith to Board

CI NAMECHANGE—Thename above is not the wrmnt name on the ilcensurc rords. You must submit a photocopy of sieoal document verifyingrams chenga (La.,marriage certificate, dtvrnce decree or legal document IndIcating retaking ala maiden name, etc.)

CI I4ll notbe pmdldng this professionin PennslvenIa alter the e,lmtion date lndIisd halowand request maclivestatus, No tea is required. Formmustetili be completed — uostIçns answered, signed and dated,

SECT1ONA • Picas. rehw the watinuing education mqubeinfl posed on the Scerfl website at vødos.oa4ovt0st CUrlon Ganoraj Board ln!irmaflon. You are requited to relate your officialcontinuing education certificates of cempteton earned for this license renewal period until December 31, 2DC’.as • ma FDLWW(NGQUESTiONSMUSrUE ANSWERED

YES NO Ifyou anew yes to questIans.2 lhmudh 12,pmld. detaiLsANDattach copies of legal docrmaent(s).IFYOUALREADY REPORTEDThE INPORMA11ONit ThE BOARDPRIORTO ThiS RENEWALYOUDONOTNEEDTOREPORTITAGAIN.. 1. Mb the ezeepUonof theone youam amently reflednp, do yoJ hold, or have yw ever held,a llnss, earUflrte, permit. ragitnhlonorother euthodzalionto precilcaa pmfe&on or occupalion Inany sIeorJurisdlaon1 Ifyouanowered yes, pleas, provide Ijia profession and aisle orjufl.dldion. UST — 2, Bracecur initial application or Wet roncwai, whicheár is later, have you lad disdpinaiy acthn liken agabist a professlonelor bocupalional Icance, cartflcate, psmit, rusflUon or other authodmtcn to jicactica a pmfesalpn ar — occupalionbelied to you Inanystate orlLtsdkflonor have you agreed to volunterysuriendar h 3. Doyou cusrénit have any’dhdpflnarjdargcs per4ng against you pefasebini or occupationalitceesb,cerUficte, pcnnltormglaUetonInany state orludsdlcfdon? 4. SInce ybur Initial application or iaafldnbwai, whTetionr is laler haVeyou withdrawnsri op cation for a professional or occupationallicense, certificate,pannit orregistullon,had en eppflcaliondeniedorrefused,orfordisolpiharyreasons agreed not to epply or reapplyftira pmfasslonai or ocaipauon& license,certificate,pennllorregistrationhi any state or JuidIcdon?. 5, SInce y’a Initial application or last newal, whichever Is later, haveyoubeenconlnd (foundguilty,pledgufliy plednob ccntendore), rerelved probalon withoutverdictor accelerated MiiabWblivedisposition(AND).aste any afmlnel charges, felony or misdemeanor, includingany dnig law violations? Note: You are not tuIred to disclose any ARD’or otheraimTnalmafter that h been eiunged byorder eta court

6. Doyou cuuenty have any almkwl dirges pending and unresolved Inany elata oriurtedotion? -

7. SInce your initial application or your last renewal, whiohavor Is later, have you had yotr DEArogiGOntiondenied, rnokedormshicted? -______8. Since your initial applIcation or your last renewal, whichever Is later, have tu had pmvidv privflegee denied, — revoked,cuspended at restrictedby a MedicalAssistance agency, Medicare, tHrdpastypaoror anotherasaiiorlt>q 9. Since your Initial apptlcaflaa or your bet renewal, whichever b later, have you had prtcfice pthdlcgas denied, — revoked,suspended, or rasticted bye hospitelor any health ours fadilty? - 1- Signatures! rnrccobon SECTION statanaVa am I I

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I PERPUSIONIST RENEWAL ______

COMMONWEALTHOFPENNSYLVANIA toao DEPMTDáENTOFSTAlE BUREAUOFPROFESBIbNALMDOCCUPAVONALAFFAIRS STATEDeMO or OSTEOPATHICMWIQNE

RENEWALAPPLICATION—PERFUSIONIST

FullName RETURNTO: State Boardof Osteopathic Medicine Street Address P0 Box 0417 Hanisburg, PA 17105-9417 City 5ate Zip Cod.

Email Address

UoennNsmbar

CheckifepwocdS

0 ADDRESSCIW$E -The ad*ess above Ia anew eddmssehd not on file with the øoard

NAMECRANGE-Thenemeabove is notthe anntnune onthe Dcnurgrerds. Youmust aIfluphotocopyofa legal document vorililna name change (I.e.. mardage certificate, divorce decree or legal documant Indlcatffi;seawn1 eta maiden name, atcj

S Itt not boprac&a,g this pMesslcn li Pernyfvehla after the epImUon dale hidicated belowar4 requesilnaciva status, Nofaa Is required. Farm must still be cvml.tad — puestons answered, signed and dated,

SECTION A .

a Phase reslawthe a’ntinbThgeduca&n requkernenWposted on the Boarda wabsilo at wMv4ospacoost Clth LxiGeneral Bawd lnfofmthorL You al, required lenin your official ntimdng education cafllficatea of comleUon earned for this fleenas renawsi period until Octobet aiieet

a ThEFO)3.OWINGQUEM1ONSMUSTBEANSWERth) •.

• #you ennveryos to questIons 2 Unugh 12.pitrw. delalfsANDattach copies a(Ie aldocwnsnl(s). IF YOUALREADY REPORTEDTHEINFORMATIONTOThE mOARDPRIORTO‘THISRENEWAL,YOUDONOTNEEDTOREPORTITAOMN. 1. Wlhthe axcepb of the poe you we ounwidyrehowifig,do you hold,orl.veyôswierh&4 a flcthisa,certificate,pm’N, rsgsjmnon oothwauttorlnlion teprectice a pufasslon oroipon intWsefliIsdIon? Ifyou answered in, •. please preside Urnprofr.alon end slat. wJurlsstio. US!’: . - 2. Since your Initial epplicailbh ox lest ian,weI, whld,snr is lair• have you had dffidpliary sedan taken ag&nsta professional or ozpa2on& license, cerefltv. pwinlL reçtsimllon or other auUiofifon to practice a pofasslen or —. ocaipafli Isuad to you ha,y ebb ar)i$a**n or hate you agreed to ohnWry s..ñnodw i lieu o!dtd$hia? 3 Do yoii cuamity have any dcJpInarj dwrges panSn agahist your pMassion,a! Cr occtaffonaI ilcanse, certificate. pamJt a, mglsnflcn hi any state orjiafadlction7 4. Since your-InItial.pplleilIon or fact renewal, whiduenrie Inter, have you withdrawnen epplicadenniceprofessional or cpatoriaI flcena.,certificate, pa’mltorwaisbollon, had an appIlan denied or mfuedd,or foreadplnarg reasons egread•Mt to apply or morn fore proIesalon or ocwpaacnalUcense, certificate,perrnftor regls&aucnin any state or IurdiclIon? - 5. SInceyour Initialapplication Cr last renawel. whichever Ii later, have iou been convicted(foundguI’, pled guliiyor pled cola ntendve), received probationwlthàutverdlotoraccolemwd rehablhjativedIsposition(ARO),as to any *iiinal dierpes, felonyor misdemeanor, Induding any druglaw dolaUons? Note: You am ml requiredto disdosa any ARDor ‘ otiter&mlnai metier that has been expungedbyorderola court. — 0. Doyou wirenifyhove any criminaldiergea pendingend unresolved Inany stale oriudsdlclion?

7. SInce your inItIalepplicatiap or your last renewaL whichever Is later, have you had your DEAregisingon a,ied, revokedccresilcied? . . . 8. SInceyour initial aipllcaUon or yourlast meawal, whichever I. kter have you had provider pdvleges denied, — revoked,suspended or resticted bye MedcajAsalflnce agency, Medlca thirdpertypayor oranaliier authority? 9. Slncd your MW,! application or your lest renewal, wMehsver is later, have you had practice pthtIaes denied, , revoked,suspended, or restioted bya hoapibi oreny heat, camfedlit’? if you ensww yàs to queslfons 2 ihmugfa 12. mv1da dsils AND aflach copies oFegaI documan ifs). IFYOUALREaDY ‘ORThDThEINFORMM1ONTOThE.BOARDPRtORTOThI5RENEWALJYOU.CO.;NOTNEEDTO REPQRTIT.AGPJN. 10; Since your Initialappileslian erycurlast meewal,whiclieverla tnt, haveyoubeen chaod bye hospital.uqivarelty, ereseazdi dlay withtiaWlngresearchprotocols,faIsl5ipgresnrth crengagfrç hiotherreseEcti mbcanduct? - 11, SInceyour inItialapplicationor bat renewel, whtchavar Is bier, have engaged Inthilntsmparato or hab1bmlin orelan of &hd vrnarcatl, haJludnogenI or oTherdzugsarsubslsnàss that mayImpairIudgmonlarcoadlna&n7 Since your Inwalapplkflori or your lest renewal, wkbenr is later, have you been the subJt of a dvi maipieceis Iawsa*?ifysa, pisoso submita copy of the entire CivIlComplaint,which mimi include the lIflna date and the dais you were served.

‘9?youwevloaty repottad the complaintto the Pond provide the docket ñombw Doyou malnlaln wwmL madIil pwlenlon& UabflltyInemnca In the Commonwealthof PennsyIsnia? If you answer - ‘liD” please provide an explanationor reason loran irnumpilonqun__ 14. Huveyou metyourcaiUnuhi educelionroqufrmiia,t?

SECTION S — VERIFICATION OF INFORMATiON IvesttdeapiUoei bhtheorln bn,,ataasupfld bythe DepMmentof Sleand hssnatbesn&tereddcothew,IsemcdMedkienywuy. I am awredtwaizrdnal pen&es forbmpef og withpublicrexqds or lnfcrna&n under 18 PaCS. 54911.

I vedly that hi lids the slstatenb iflcoon am Sun and coaecl to the best of my knowledge,Infonucn and bseL I understand thai fthe statement em mete subject tots pensifles oilS Fa.C.S. 54904 (mlatng to unawumfaislSian to ainhoifties)end may nult In the susperalen. rsvoUon or denial of myline. caiIftcata pernll orregictrallon.

Signakn of Licensee (Mandator9): -riçlstathn ______

COIMONWEALTHOf PENNSYLVANIA DEPMTMnt or SrAi RuREu Of PROFESSIONALANDOCCUPATiONALAFriRs STATEB0ANDo OSTEOPAThICMw3ciiE

• RENEWALAPPLICATION— PERFUSIONIST

Full. REWRNTft

state Bawd olbsteopatFilc Medicine SWat At&ess PD BoX8417 Hanlsburg, PA17105-8417

City . State Zip Code

EmeilAddmn

Uãnsa Number

Stink Ifappropriate

D ADDRESSCHANGE-Thepddreos above its now addna aild not on filewIth 11wBaud -

t NAMECHANGE-mi hathaetove Isnottheaarentname on theUrerna ricotta Younwataubmfta photocopyaf a legal documèn nrtifrg•nmne chai’ge (l.a. rnanla9o certificate; divorce decree arlegal documoit lhWcábng ñtaklng dsm&dmi name, ota)

U Iw*not bepmctl&g th plofo5slcn InPornisylvinlaaflarthe eçfradon at. bdcata1 beiowand itiuest ffiAritvaslain. NOISeIs rqulrat Formiflaststiobe completed - questions nnmd, cloned and did.

SECTION A . • • Plesearè&4ewthaiUnWng edutlon raiulremenbpqØd millieSoEitnib&ts at &taL Clái GenerelScott InmaUan. ‘lou ale ivqukedto mtelfl yoiirclTIol4vonUnulng iduadon cerUftautesof conipicuon.am.I f this Been.. renewal period imfflOctober31,24*’ . . .

• . WE:FO1LOWINOQUESnONSMUSTBEMSWED .-..; •• . . .. - YES NO ifyou enswwpa to qUàuns2thmugb RprcWde detáA each àpfraf kg&doersnt(s). WYOUALREADY REPORTEDThEINFQmSA11ONTO11* BOMD PRIORTOTin RENEWAL;YOUDONm-tEED TOREPORT WAOAJN. 1. Wilitheemepfai d(th, oneyuan cwmniiy-i,*j1& tu hold.or hse.you everheld,a licenea,cerftflcatzpamlt crater authtdzodan te practicea pipMsdoncrotipallon hi any slate orjudsdlction? flyer. answered )SH, please providethe ptofenlon sill sate or Jwlsdlct on.

LIST: .

• Z Since your initial application ortbat renewal,whichever Wirier, have $oubed disdpliñaiyfln taken eg4 piufastienal or oceupatlonal Ifânse, cs,sftte, penlilt iUtsntlon or ol,w euthffon b pradkj a rofes&on or onoipeftor,Issued to yotiM any sate Urjihla&on orhave you weed to vclwit.y surrender biBegof dlflne? — S Doyw mneriiyhSveariy issdplhary tharç paidlag aflil yourprofossnal cc ojpaUonaI tlwhsa, osnlficale, •peniflareglen1l&i U,ajiysflmJjgtt7 .. . 4. Slnoe NeWelapplkadon a, liii tat.wsI, whlthewrk buet hawitu withdrawnen oppicehonfora profenahinal orceaipsIJon Doej cetifficata,permitor reglifl$oo, had an.ppflcatan deniedatenmod, or ford11nary reesoOs . ig.ad not lo apply or reepplyfor a .pofeülost or ocwpa&nal IICanS%ttâ1ta, r!tor gflflQ liiany Iteta or • JUdsdldlon? . E I. Shies your InWel application orbit renè*aL-wftuihn, lair. hgve ,vã been ri’4ded (foundcuilfy,pled guiltyor piednot rnondwe), secved.probathqu4thout vgE or accented rehabilitativedloeWon (ARD as to any atoliI awigee. folonjar mladenisanoc lnddkc any th law Molafions? Natal You em no requhed to disdoes sny MID or — waimbial mihartiatjmahemgudboedwd.awt

.8, DoO9 cwnntiy haveanyakAlnsItherga peiidWlgand unreatlved friany ella oflaisdiclian? .. - — 7. 8kw. you Initialapplication or sour Tealrenewal, whIEli.vhrIs later, Haveyoubad yawbEA reglahationdsnFsd ! • mvokUWnsbted? • - t SM.. yoiw Initial applicaffin or your lest renewal, whichever Is Iat.r have you bad praildar palsilogas denied, — mv.kA&-ámperaled or raUlded bya Medlr Astfl agewy, Medicare.t*d pfl isyor àfanotherauthodly?. •. I. lice, your Initial application ãyour lest nn.W4 whiCiVN ö later, haveyw had prac&s ptvBegeedi, - inked, s., orrabbled bys hosplt.l winy hsalth iedhly? tnocUon Signature statementa [vedfy SEC11ON I verify p aota that th$ of Dr bi we this B the the denial Licensee — made applcaton VERIFICATION cdmthaf s1atemen

trju - of auboct ORThO myilcansa. (0. 91 gazer (Mandatoiy): penaffici you [ski you Since Have or lawsuit? orreseerth SInce Do Since In No to abuse ThEINFORMAtICN you this previously the wejonred. the you jtà ptease your your coffile, your for OF odfl nwlnn uppilcavon penaldos of i met mpateg to INFORMA11ON yes, aIhvl tacl1l’ initial Initial InNiel prQvlde questkni your reported foimatnsupplled pleasa wreni pennlt application application application of lt cntnuing ornsrll. am with iB an via submit hue or TO PeGS. 2 p&1o medli the explanation IA reglsfl QWCLgh ThEOMD tog complaint end OdUtiDn or or or rar&bthnnaUon a mace halludnogerd 54804 professional your merest capyof your last Von. by 1i,fri&tif rob the or renewal, last last to requlromen? (relating reason pie 0 to PRiORmTIflSRENpVAt the the renewal, renewal, tàcals, the arhnentofStaloand entire liability Scant or whichever best for dituils to other tWr unswtm en Civil whichever whlchver under of lrurao prtvf etempHo drugs my A)W Complaint do I! 18 knowiedge. rawth falsifiesfon later. or sUadi the Pa.CS. in Is It substances has docket the Later, n*ant. later, have copIes notbcen which Cammonwnhh YOU 5 lnformdcn.end to have 41 eiaafl have you number authodUes) QONOT that 1. must of e1ieged you yots altared legal nisy beei fri beni inciude.the ottr NEED lmp&rjudgmentonzwvinagon? doczanenffrj. orotho%Ise of In and aarge the bel&L the Pannayivanla? rezewtb may sub$tt TO In wnpemte filing REPORT bye result lunderotand modified of mlsnduct? IF hesltoi, date a in YOU dvii the if orhaNtual )TAQPJN. endthe yod in nflracUoe suspernion, ALREADY Lnivdfl, anyway. that anavier dab false. uie I ______ThE______

COMMONWEALThOFPENNSYLVANIA DEPARTMENTOFSTME. : U BUREAU& PRor8sio,Ln ANDOCCUPAtiONALA$1’MRS STATEBOARDOFOSItDPATWCMEDiCINE

RENEWALAPPLICATION— PERFUSFONIST

ThUNn RETURNfl Ste Board of Osteopthlc Medicine SUm P0 Box 6417 Hanlsburg,-PA 17105-8417 cay an rpcode

EnmflA&ess

Ucenea Number

Cbeckitepjropflats

ADDRES8CHANGE-The addreoa above is a new address and not a., tile With(ha Board b NAMECHANGE- Thesame aboveb not the anani nameon the iFceqsursrecords. You must submit. pholotopy bYalegni dboument nrjf4n name change Q,e.,manta, ceriffleata, divan,, deava or leqe)documonhlndkaflngmbIthi eta maiden name. ate.)

o Iwilnotbo pmoUdngthisprofession InPenasslvantaaltar theeçahadcndata thdtatad belcwwidrequestkiadve sUtis. NqIao inrequired. Fcrm must sell be coqnnlefed-quesUofls answnd. signed end detad.

SECTJONA • Please rWewthewithiAngeducUonreqiatemfl postedon(hoBore weWftsatr4os.oaaovfost Qick on GennmiBoard .Infeimaiori.YOUore nqulmd to ‘etaft your omelal continuinG sFdOn WSflCStGS o(conwhtlan aanwdlot this ilusnsorenewal •period until Cctdber 31, 2016.

• THEFOLLOWINGQUEStiONS MUSTSE ANSWERED YES P ftyaa anmri Is qun&nr 2 thitugh 12. pcil* details ANDatath cefiin elk alUoczm,.nq’sj. IF YOUALREAZY INPORMAflONtO ThE 50MW PRIORTO ThUSRENEWAL,YOUDONOTNEEDTO REPORTif AGNN. 1. wit te exeeptonDifl CI*YW eta ennw rningdoyou had, orlwve tu erl e kaisa. iti!mio nt booor other t&s out.6, to ncEce a pdussimi or oipe ban hi siy eta eflhien? ITyou anwnd pe. flase provide thu protsa.Jon and afl ofluledlcton. Un: 2. Sines yoiu inftia appDcseon or last renewal, wtichawr Is hut. have co had .4A...g actiontaken agaMsia jsofesalcr4 or xnçauawl basics, -antSta, psnfl. mg’sbathn or otherauth mEan t prado. a pmlassbooor ooaipedm Issued b )tu ti s’y stath orjwiodidon at have you agreed to volimthiyilflTatY’ST ti Etu ntcflck,&e? — -3. Doyou armnty. have any dudósy dages paidhig aiost nr pn,fasbiàl a ooa4aUend loam, certftcale. pamiltor r,sfllal in any aIsle orpiffdten? - — 4 Since yDLTmEtal appflaidon a last flnnhL whidievor Is Iler, han you Vml&al%nml appIlco, hire pvfeeslni a oca4an& Ron cerVfleaiops’mftw reØebaCon,had., apØeadondeniedorrefined.orkr *(nary macn • Judeagreed net to áx4y a raapØy Ia a professional or ajpebon& lame. cwfficous, pemift or msuebaEi Ii any elate or ri? - E — 5. Shoe yaw InWaIapflcadon a’ last genes), whichever i io*. hdveyoubeancontded (Found J, pled 94)y a’ note coIlflero),rtQed probeb, wttim4 vert a aoedaated mhetllM sposIUtm CARD);a to any almfr,ai ! dir lalonyat mlemsn, tickidag any drug law vleleUone? NoIs Yth era notnçilred to cEadcá amyMD or othetaktinel met*thMhM beamapunged by udw eta court ‘S Doyoucunanllyhave.nyaflhrai diapes pendingend unraoi Ineny stile flitadlalion?

7. Shea Initial eppllqs*on or your lent reh.wel, whIcha’sr Is Jatsr have you had i.vw DEA rsØfltIon denied. ‘ rwvobdonusbfc%d? B. Since heir Initial appIen or yaw bat renewal, whlchanr hi later,, have you had ptwl4er piMlegea denied reveted,suspendedormetidefly. Ml Ansishincaaflenqt Madoaro.thhdponypator orenbtheraudnny?

• B. Ethos your initial eppNiation or yam kit renewal,whichever ls,latar, lmvoyou had practice pdvtioçaa denied, — resoked,suspended,oriaMdsdby a hoefli a anybeaM ae dftb’? 1

• if you .nsiiwi.s tà questions 2 thruudh i2pstlvWa details AND attach copies allEge! doownent(s). IF YOUN.READV REPOR EDThE INPORMAT1DHTO;ThESOARDPIOR TOThiSRENEWM.,YO J.PQNOT.NEEDTOREPORTiTAGN. - 10. SInce yaw IntUitapplIcation or your test renewal whicheverIs War, haveyou been d’wgodbya hospital,tmtversRy, — resaardifadRywithviolaig rarch ptotn, bt&JMngrnaard, engai Inotherrnesrch mlsceciduct7 11. SInce your l&tI&appilceffan or tilt renewal,whiclienr Iabtar hav, youaged hi the blampe.ata or habflü&use a abuse ofalcoholornarcod, hafludnoprilesorotherdrugsersubetances thatmayirnpalrludgmentor coordination? 12. SInce your InitialsppUcadon or your bat renewal,whicheverIs later,haveyoubeen the subject of a dvii m&pracffce lewsiji? ifyss, plessieubmlt • copy ofthe entire CivilComplaint,whichmust Includethe airo bls aridthe dais wuwarenevod.

9tyou previously reported the complaintlo the Board provide the docket nunther 13. Do youm&nbhicznaqt medical prcfsnlonai liabilityfriennca in the Commonwealthof Peiuns1vania7II you answer ‘No”please pm-widean nplanaffon or reason 1wen enmption request 14. Psveyouma yourwnUntfl educeuonnqi&emonts7

SECIIOr1 B - VRIflCM1ON OF INFORMAnOtI

I en ante ofthe aimirof panaWes temperingwThpublicrar or 1nnnaHon Under¶6 PeGS. §491t

my kr.orleige, information belief. I that false I verifythat the swiemonts mthis sUUsn are no and rect to the best of end undenland statements are thsdosubject to the ponaitleeoils Peas. § 4904 (relatIngto unawomfalsificationto authod€ss),end may result in the suspislon. ragocaon ordenial oFmyIcerisa cerfihicate,pemiit or rsglstm&n.

Signalure of Licensee (Mandatoiy) GENETIC COUNSELOR RENEWAL COMMONWEALThOFPn*ISYLVM4IA vsnmJearaFsrAn BUREAUOF PROFnSI ORALANDOCCUPATIOMALAFFAIRS STATEBOARD0 OSTEOPAThICMEcicINE cao RENEWALMPUCM1OM - GENETICCOUNSELOR

F HNaMe • RETVRNTO: State Board of Osteopathic Medlclna Stoat Address PD Box 8417 Harrisburg, PA 171OS’8417 City 8t. Zip Code

Email Address

License Nuntdr

Che&Ifcppmpdats

U ADDRESSCHANGE—Thend&nn above lea newaddress and not onW. Mdi tha.Bóntd 0 NNIECHANGE—Thetne above b not thecurrent nameonthe lloãnn records. You ma submit a photocopy of a legal document vfl4n name change (La. mmWsp ceruften, dkaite decree or Iog.l dacinnt Indlcs1lr, mftWngof a maidenname, eta)

t3 IMI notbe poddrg thIsprofesdcr In Ponnsyfvailaafterthe ougulialandais hdhxtod haiWiand rsqestInsWs sna He fee Is requtred. Fain must still be contieled - punon answered1&wiad and dated.

SECtONA - • Please revte# Thecen&xiThgeduUon requflments post.d on the Boards wabib it iwn..dc a,a&oct GI& on Ganami Board . IOetthsrt2t%Womiaton. You are requfldlo rWaffiyir ofllcWcaaUrn9ng educaum, oartfficales dcoqfltlan earned fat Thb license renewal

. ThE FOLLOWINGQUESTiONSMUSTSE ANSWERED - Vvu nwwer Wqcen 2 th.vaØ 17, pmvWa *tab AND aflch copies of iegatdazth,wz4 YouALREADY i• REPORTEDThEINFORMA1IONit THEBOARDPRiORTO.Th15RENEWAL.YOU001107 NE TONEPORT ITAGNN. • 1. WIththe aiceptknotlhs onetuam réne(rç, do)va hth orhave et nrhoM, • lioeriss.caitlioato, potrnfl, rnIsflIlàii orothrsuthodUon to pmWcea proleaalcnoroxupsUen Inwryateteorjur4awj if vu mnmveredyea, . pins.uS______provide the pmfesslon and elate orjifldctlom 2. Was. y&winhial appileaffon at lust renewal, whkhaer Is later, have cu nd dbdnzzy acUon taka egobiat a pmfessfnl or oipaUonat kense, ceflfrta, pannft, re9simflon at other out lion to padioc a pmfsIon ur ocwpadonlamindto ,tu Inany an orjurtedWionor have you agrepd tovohjnthiyawmnderhilieuofdisdplhio? 3. Dotu cunendyhave any dbdplbimy diergea pandh agaInst your pms&oiW or ocuJpaVonaJIanss, cretficato, pentft orregloflifonInany state orjOdsdan? —______‘4; SInce yoUrblUe!appflcattn at last rapai.ral,.vh is latar,,hava you withdmcnaWepplicoffonFora pmhs&&ial

• or ocwpullonM lone, cortRte, permitorragatreson, had an appflcson deniedor refined, at fordleflnary /aasons ._Jfl? agreedcot to eppfror reaWy torn professIonalor oapainl tree, ceffouth, porraftat mIslmSrei hiany state or 5. SInceyour InIdel appITouUbnor lest reneal, wfrIsh.vw lu later, Haveyou been convicted(Foundguilty,pled dty or pT& note raidn, received pobatlon Wthoutiedid or a$w&ad rehaNitafre dlapoelion {ARb) as bny afmhiei dwges. fdatiz or mladernwror, Indudhig any *r law Wciadane? Note: Youwe itt requb to cipdcee wry ARDa • other ansi mattertat has bean emq.d bycrdrda coca I, Doyou nfl have any atrtwT daggou peidri and unresolved hrany site atjusisSdWr7

7. Slnsá ymz If! apllaaflon or yew bat renewaL dulchevàrie blat, have )ti had your DEArs liban denied, rwokedorresbldcI? L aMa yoir Inil appKcn or your bet renewal, whIchever 4 liter, tae you lad plovider prMagee denied, rgveqd, ampwideda ,..kk.t.J bya Meoul Aaa4anca .periny,Madcare.IC pcly payu at windier aueicrtty? Shies.yatg InlmJ .ppflcelor or your last m.anL wMcha 4 flr. lie,. you had pre flhJeges denied. rscbd, mspu,dad, or ,pb bye hosplWoraiw healthcars bd*7 : to.Sine. vir hit applicatIon at year test Neewat whWwnr 4 bar, tin you beiqithargedbya he. lW,unJveraP • - drjnwch ha%’a vloIafl research pdaouls hieIti; rnewdt. Creng*ç Innet reaewthrnkconója7 recaUon am j

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I COMMONWEALThOF PaNNSYLVANIA DEPARTMENTOFSTATE. BUREAUOFPROFESSIONALANDOCCUPA1IONALAWMRS STATEBo*m OFOsmoPAmlc MEDICINE 3Lkly Leo&2 RENEWALAPPLICATION— GENETICCOUNSELOR

PUNNan RETURNTO: State Board of Osteopathic Medicine reetAddreaa P090x8417 Harrisburg, PA 17105-8417

CRy - - Stat. Zip Coda

Emall Address

LlcensdNurthnr

ICheekIfappropriate

El ADDRESSCHANGE—Thuaddress sbove Is anew sddresa id not on lila wIThthe Boird o NAJIECHANCE-The ma above Ii not the wàwnt name on the tcenswa records. YoumuM submit a photocopy eta legal daautisnf vaflMnn name change (I.e., mantagg cenWoate, divaice decree or Ispal dowmeM Thdlollng rateklngste maiden name, eta,) I

C Iwillnot be praoUclngthIspmfrsslon h Pedna$vfl alter th. eç(mVoh data lMcoled belowend mquest(nafve sSa • Nafoe is reqaired. Form must aWl be comejeled - questions answered, signed and dated.

SECTIONA a Plse ,euw the nVnuIn; ethndon rtquIrenisn pealed on the o;rds webofteat YNM.dcs.pa4oWostGlccon General aoai-d . Infomevon. You era reqtAied ft robin your alflcbl cprifinulng idcrna&ñ deflWcata. of campleesa earned loTIhie Ilcoiws renewal partod Until Oober 31, 290.

‘. ThEFOaOWNG QUESTiONSMUSTBEANSWERED • Nyouanswsr yes to questions uougb 12,psuvwddetefls ANDittech copIes qf legal doe mlâ*) IFYOUALREADY REPORTEDThEINFORBIADONTOThE BOARDPRIORTOflilS R9EWAL, YOUDOHUTNEEDTOREPORT rrAGAJN. 1. lt,n pflonoftaonoyou weozr.neyrena1ndoyeu ho crhaveyoue.ierheb,e icaise, tlIcata.pemilt - reçSadon or other suthctzatn t pràc& a profession or ocwpaon In oiiystale orJu$ecCcci? if you answered yes, ph... pm%fdethe profeasio@and slats ei Jwlsdktion.

. - 2. Stneeynurkilff& apcUcatlowor last ranewol, whIchever Is bter have tu md dIsdnsry action lekeft against a pmfosozI or occ.ipakai& !Lrnae, redEta, pemh, mglsfl6on or other shjthoitzaffcato prWlae a p,ofaslon or — oçeilon Lesuadto you h miyslatsotjwlsdfruon or have you ewecd to wwity marul& kilieu of dlsdplhs? — 3. Do you orn.ndy tave any lsdkwyâwe paidk,g agahial yow probssloed or occupaoaal icensa, cecMcata per torrsglstsUonhwwststaorjw?sdttmi? - .4. SInce your InItIal applltaCIon or last enawal, whiohiver Is titer, haveyouwithdrawnen ap;tlcaffon tars ptofttalonzl or oUonaI license, c.rftcaW, permItor reglandon, had i apptcation deniedor rasW, or for dhdrwy reasons açrsed not Is ply or raapØy for a protesdotul or occupational license, certficah, pnfl or redstukn In say at$a or JialadIdBonl . 5. SInce year lnIUelapplication or tilt renewal, whlshinr Is later, have you been convictedround guilty,pied gMty or pled notecantefidem),receIvedpmbeuon withoutverdIctor eccelejated rehebVltiuved5poslion (ARD),as In any tlmtnal thames, felonyor mademwicr, lnchzdlngany drug law vlolsVoris? Note:You axe not requIredft dladose any MD or other atsnhal thafterthat be ban ungod &gorderofa coWl. 6. Doyou wnenW have any cdmlnalrMarea pendIngand unresolvedlniny stile orjudsdrdlon?

7. Since your Initial application or your lent renewal, whichever Is laIr, have you had your DEA reglsbadon denIed, revokedorresulcled?

• 8. SInce your Initial .ppILUon or year last snewaI, whlckewr Ii later, haveyouhad providerptMagaa ónled, — revoked.suspendod or restrictedbye MedicalAssIstance agency, Medicare,thIrdpartypayor or anoTheraio? - ! D. SIncEyour Initial application or your list renwaL whlcbsv.r Is bier, have you had frà&oe pflvll.ges denied, revoked,sltspcidad, orrasbiclad by. tiospIl or any haste, are fadtty? - 10. SInceyes InItialappllcadon otyeurIast renewaL whl*sver le later, have you beenthai-gadby a hospItal, amlvemily, — orrazcarch dIty Wthviolatingresard, FôtcccIt, febWnu rassarch, or engagingInotherresaish mlsthnduct? if you answeryes (0 questons 2 thmugb i aiáWde details AND attachc!es al’legal documonl(s). IFYDUALREADY REPORThDjHEINFORNA1ONOThEBøARftRIOR3O This RNEWAL.XPUDONOTNEEDTo REPORTIt AGAiN. 11. SInce your InwalappVcaflonor last renewal.whichever Is later,haveyouengagedInthe Intemperate or habluml‘ma orsbiise ofsIhrA ornarwUcs,haIuclnogenI orothar dmga orsubstances that maylmpairludgmentorcooidinaffon? 12. Since yarn InItialapIitIon or your 1a51ranovwatwhrotmvè Inlater,haveyoubeen the oubjectofa olvOmolpmcdce • Iesull? ifps please aubmita copy of theeMira CMI Complaint which must Include the filingdoi and the dqtb wu were bind. .

— if you pmiouely npo4ad thecompleletto (hoBoard provide thedoctet number 13. Do you maintaincurrent media professionalIIabILWinmimnogInthe CommonwIth of Pennsanla? II you anevar ‘Non please providean ezpbnmlon or reason for en exemptionsequEL 14. Haveyaumelyourrnndnulngeducationrequlrenients?

SECDDN — VERIPICM1ONOFINFORMATION lnrtfythatUdsappflcabon Is frithe oflgirtaitoxwats eupUed byths Qepflnontol Stateand h r,otbewi&tamdofool.fWsemo(flfiedfrionyway, I m mwroof tha almlnd peisidee krtampot.g WthpLtflorecords vrlnfwmeflcn wider IBPaC,& §4911.

I vadly dm1to stateffieit In th am true end wrmtt to the heel of my knmlodge. Inbnnff on and b&eL undamtandthatthe stemenIs we made subJct to the penfles oilS PeGS. 494 (reiathig b uniwomftkftUan wsthodueu)an4 may result Inthe su,ensIon, revoJoa ordenialamy ticeiso. certificate,pfll ocrebimtion.

SIcna#e&Ucensee(Msndatcry): Data:

I COMMONWEALThOFPaNSVI,VAWA DEPARThIENTOFSTATE BUREAUOFPROFESSIONAl.ANDOCCUPATiONALAFFMRS STATEBOARDOFODWOPAThICMWJCINE

RENEWALAPPLICATION— GENETICCOUNSELOR

Full Name REtJRN1b: State Board of Osteopathic MedIcine Street Address PD Pox S411 Harrlsburj PA 111064411 City State rpcode

.Ema Address

Ucense Numbar

Chock Ifappropdato

O ADDRESSCHANGE— Theaddrees abow Is a new addmsa end n.j on filmwith the Hoard

O NAMECHANGE—Thename abdve Is not the.wrront namon the IIcansurererds. You must submit a phelocopyof a leal document nrIfyin9 name change (l.a., monlege certificate, divorce dine or legal documen( Indicating retaking ate maiden name,vtcj

fl IWVnot be practdng thispmfesstonInPannsylnrib aftertheeçlmUondate Indicatedbebwpnd rsest inaoth’aawe. No fee Is required. Form must attn be ctmpeted— cuestiacTs gnnvered, signed and dated.

SECTIONA

a Please rmlew the conUnuingeduVcn requkemonts posted on the Doarflwgbsba1ww.&aaaoat CiI&on Gem Board Intonation. Youam required to retain your official continuing education cerlulcaa of coniploffen aarnad for thI Ucarise iWiewal pitted until October 31,20* 2io • ThEFOLLOWINGQUESTIONSMUSTEMSWCRHP ffyorz answer yes ft quesflons2 through a provide derails ANDattach copies of legal dooumwis). IFYOUALREADY, . REPORTEDThE INFORMATiONit ThE BOARDPRIORTOThis RENEWALYOUDONOTNEED10 REPORTif AGAIN. 1. WIththe escepdon of the one at era cisrrtiity renewing,Uoyou hold,or have you ever hMd.a lena, cereitcets. pemift. restmUon other authortation to pra1 a profoasjonr ocoipatioc Inany otalo orjudsdlc&n? IIyou answered pieces provide the profaaalan end MaWat Juftadletiorm. LISt 2. SInce your inItIal applIcatIon or hal renewal, whichever I! later, have yai had dlsdpllnmyacton tek against a . pmhs&cnoi or otaqmffonel lltaa ce4firele, permit rØteffcr or otiwr authat&lcn to wac4co a praafon or — onpallon Issuedlo you hi any stale orjudsdtctn or have you agz&d te vohnt aurmndorIi lia,iofpithe7 3. Doyou idy-have any dIsaUnay thvges pend(i agakist your pmçftsslonalor ocaipaffnaal Iconse, certficale pdnnitcrgf.!mUan inany state crJurfsdlen? 4. SInceycur mEWappucaurm or last rinnçwtildhiWris tat. have fldrawn enepçta&n Mrs pte(esslvnal or oc1pan& Ursa, cardicale, peanit or m5rsfltion, had appksHoc denied w refissed,or Mr &sdpC,ry reans agreed not to apply or roapply Mr a profqnaJpr opatlomI &ense. certificate,paeaN orreglanxa in any ewe or

— 5. SInce your initial application or last renewal,whichever Is later, have you been rwictW (lctmdguity, plod gufllyor plednob Meidn), received rmbauon wiftioulverdict oraecotomled rMiab1tahe dposWcn (MD). to any ca1mln dwpea, fairy ormisdemeanor, Ixkrdrç any drug JeWvtelatlus7 Note: Youate not mqSed to dtac1os any MDOT — othwcdmtoal matter itt has been ertpttged by ordei of a coat C, Doyouourrentiyha any atmkI diarg.s pending and unresolvedinery aMa orjurction7

7. SIncayour bifflalappllávon or yowiat rsnewa tlchsver t later,haveyouhad ‘ow DEAralsnflori denied, . rsvoêsd orasfrtctedl B, Skit. ‘pow initial application or your Wet renewal, whictiever Jo lata. beet you had pmsldn pflWgq denred. — revoked,suspended at restricted byaMedlI Mslslance agelity.Medicare.thirdpaflypayor at anotherauthorIty? 9. since your Initial application or your teat renewal, wbiohevar I. lets,, have you hed practiceprlvegcs denied, revoked,euspended. orrestided by a hcspitelor any hth a fally? 10. Slnceyour Initialapplication or your last renewal, wbkhewrle later, have you been alamad by a hospital, wveraIty, orressardi Viol th’Aolatbgreasatzfl ptotocals,fuWy*qtneathh orengang Inoilierrosearth mbceralucty #you saner yes to questIons 2 through 12. pmW details AND sttach copies of legal documeaff4 IF YOUALREADY REPORTEDTHEINFORMATIONTOThE BOARD:PRIO 70Th18 RENEWAL,YOUDONOT NEEDTO REPORTITAGNN._— 11. Suite your Initial applicationor last rniWal, whichevar Is bier, havo you ensged Inthe InWnpnta or bib waluse or abuse oI&l,ot ornarrnIi. hwiudn nI crothar thu onubsances that nay Impa!rjuneMor 12. Sliica your bikini applIcatIonor your lest renewal, wblcliqw Is later, halFoyw been the ;LMactala dd malçncfl bws1t? Ifyea. pfeaae submits copy of the smire Clvii Complaint which niust include the llflp, dale and the dete ru warn served,.

‘It you prevlouaiy reported the complaint to lb. Board provide the docket number U. Do you melnJn anrent medll prefesslonal Vabfli’insurnn In the Conw’omveaithof PennsyIvara? If you answer MNo please provide en ezj,lanallon or masai for Sn exemption request 14. H eywmotvurcontiminp aduUon requkaiiienb?

SECTIONS —VERIflCA1ION OF INFORMATION.

and has not beonaltered orothwwise modifiedInany way. I Ivetity thattis appllcaVonlain tha oflglnalftnnatas suppfl& by TheDcpartmentoYSte am aware ofthe 1mIna1 pene.’UeaforIsmpodng v4thpublic nrds orhthmialon Under18 PaaS. §4911.

I that I .arl4. that the abatements in this oULn ere baa ant asrect b Urnbest of my knoydedge.inlonnalon and baof. undnaid lsa statanenta em made sutect to the perIlles of 18 Pa.C.S. 4SG4(relaUn to LMSWCfl faiskiceilonto authorities) and may result In the sRJsponEIvn, revocatcsi or denial ofmy Jocose, carflflcate,veimftormgtsmffcn. Attachment C AMERICAN OSTEOPATHIC ASSOCIATION

TREM ING DU Ft IAMI LI AND YOURS

U.S. OSTEOPATHIC LICENSURE SUMMARY SEPTEMBER 2019

HOW TO USE THIS SUMMARY R1TRODUCflON

The Osteopathic licensing Summarycontain, tempt information about the licensingrequirementsin each stare.DO, who gndtnted more than 25 yearsago, with fewer“stzndardizc&’ardenthh, maybe subject to different standards of eligibilityfor licensure. Their questions should be addressed to the specific licensingbawl involved.

Genemily,a licensean be obtained in onevi two vnfl;

1. &aminadon administeredbythe board.The bond mayprepare its own examinationor administeran enwinadon that his been prepared and puzchacd from a specializedagency.Today, the UnitedStates Medicallicensing Examination (USl.flJi) and the Comprehensive OsteopathicMedicallicensing Examination (COMLEX-USA)are the most widelyused tests.

2. Reciprocityor endonetnenc of a licensepitviously teethed from another state.No applicantis ever entitled to automaticreciprocity,for alllicensingboards rcscn’a the tight to cacrdee discretiqnindividuallyin evaluatingan applicant’spersonal,professional,and moral qualifications.Also, the licensepresented for reciprocityor endorsement must usuall havebeen issued an the basis of a written examination.Manylicaung boards are not specificabout the slateawith which theywould Itoprocatel while we have attempted to list as much reciprocity liSonuadon as we hive, DOs hiving a question about the eligibilitycia particular‘late’slicenseshould address it to the specificbaird. givingdetails.At one time a majority of states had basic science requirementa and administered a written aamiration. This explainswhy certain bond, wi reciprocate with certificatesonce issued bysates that have now abolished their basicsciencelaw.

Pie-professionaleducation requirementsale not described,althouth theyare retained in manylicensingsatuta Some statutes even continue to specifythe extent of a high school education that an applicantmust hive. The admissionsrequirements of allaccredited osteopathic colleges save to Insure that virtuallyallrecipientsof the DO degreenow have a mLtum of three yearsin co11ege,and mort have a BA orBS degree.

Fees have beengivenwhen bfonnadon wasaniliNe, but since feeschange more frequentlydun any other requirement, usen should enter to Snd occasionalchanges,and should, of couze, rely on the latest information supplier1bya partathr board.

MEANING OP TEENS

- Many sates do not adequatelydefine the scope of a physician’spncdce rightsin their licensingstaaite;be he/she a DO or a MD. Depending on the state, a DO mayreceivea license to practice “medicineand surgery,”“osteopathic medicine and surgery,” ‘osteopathyand surgery,” or “osteopathy,” and allmay convey the same tight. For brevity,the AOA uses the tam “unlimited” practice rights,which for practicalpurposes, means the treatment, of human ailments,etc., by any and all methods; and an be comparably described as the same rights receivedby 1.0,. If the scope of practiceis not listed under an individualstate’srequirements, it Is “unh,m

Educational requfernents - As previouslyindicated,this heading is usuallylimited to summathing the state’sdefinition of an approved osteopathic collcác.As a practicalmatter, gnduation from an AOA accredire4collegeshould satisfythe professions! educational requirements of allstates.

Posteraduate tnining - This section detailsthe number of years and die type otprognms tharal satisfy the postgraduatetraining requirement.Allsates require at least one year of postgraduate mining. Some states requiretwo or three years of training. r

- This reranrefersto the licensingboard empoweredto recommendor actuallyissueosteopathiclicenses.Thcçe are basicallythree typesof boards: (1)DC - composed entirelyof osteopathicphysiciansandhas the responsibilityof grantingunliniltedlicensesto DOs; (2)MD - composedentirelyof t,Ws but havingresponsibilityfor grantingunlimitedlicensesto both DOs and ).Os; (3)Composite - composed of DOs and MDsin varyingratios, but usuallywith a majority of MUs, and hasthe responsibilityof granting unlimitedlicenses to DOs and MUs. In addition to the physicianswho sit on state licensingboards, publicmembers are now included on thc board, regardless of the boarJ composition.

Bond address - lIds sectionlist, the bfficialname,contactperson, addressandphone number hr each state’slicensing board.

Osteopathicmembers - Those DOs who sit on the state licensingboards are includedin this section,

Sunsetlaws - Manystales include“sunset” provisions when enacting licensingboards.In such cases,the authority of the board expires,or “sunsets,”on a givendate unlessspecificallyre-authorized by the legislature.

Examinationsaccepted - This section lists the examinationsaccepted by state licensingboards. Currently,the two national examinations recognizedby state licensingboards are the COMLEX-USAand the USMLK Both the COMLEX exam and the USMLE are three-parr nationalexaminationsconsistingof both written aaminntions and clinicalskillsexaminations.COMLEX Level I or US’?4LEStep us usuallytaken during the secondyear oflncdicai school; COMLEX Level 2 or USMLEStep 2, both the written portion and the Pafomunec Evaluation,is usuallytaken in the fourth yen of medical school; and COMLrnClzvel 3cr US’MLEStepS can be taken during the first yen o(postgraduate training. So when it states that an examination,i.e.,C0l.thWc, USMLE,etc., is recognized, it means alIthe Levelsor Steps must be succcssfillypassed.

The National Board of OsteopathicMedicalExaminersBO?.O developsand administersa complete and comprehensive examination programrot Dos -- the Comprebradve OsteopathicMedicallicensing Examination (COMLE9. The COMLEX replaced the NEOMB exam.TheUnited State Medicallicensing Examination{USML is the one,singlemedicallicensingexamination for ailopathic physiciansand replaced the FederationLicensingExamination (FLEX) and the National BoardMedicalExamination(NBME).

license fee - This area containsthe cost for securingan unlimitedlicense. Fees changemore frequentlythanany other requirement,so be sure to checkwith the specificlicensingboard for exactamounts.

PedesationCrtdej{jgationf prviceIFCVS1- The FederationofState MedicalBoards(ESME)createdthe FCVSto veti’ a physician’score cstidentials— identity,medicaleducationand training,and examinationhistoty. Whilea majorityof states willacceptthe FCVS,therearesome licensurtjurisdictionsthat willnot accept the FCVS Thesejurisdictionsthat willnot acceptthe FCVSrequitedirect sourceverificationforphysicianlicensure.

Reciprocityor Pndnnement - See the appropriateparagraphin the Introduction.

Spcthl licenses- This sectionlistsinfonnadon about availabilityof temporarypemiltsgnndng practiceprivilegespending theissuanceof unlimitedlicense.

Renewal Statesrequire periodicalre-registration.Dates and feesare givenwhenknown.

CME requirement. Continuingmedicaleducationshallbe Inan area of the physician’spractice, reflecttheprofessionalneedsof the licenseein order to meet thehealth are needsof the publicand includeat least one contact hour of trainingor educationin ench ofthe followingtopics:(A)In&ctiousdiseases.including,but not limited to. acquiredimmunedefidencysyndromeand human immuonddfldenq’virus,(B)riskmanagement.(( sexualassault,and (I)) domesticviolence.Additionally,for registrationperiods beginningon end after October1,2010,courseworkin culturalcompetencyis alsorequited.

OsteopathicContinuousCertification(0CC — 0CC is a processin whichADA boardcertifiedDOs an maintaincurrencyand demonstratecompetencyin theirspecialtyarea.Exch ADA specidleycertifyingboard developedCCC requirementsimplementedas ofJan. 1,2013.0CC is con4riseaors componenti: 1) unrestrictedliceasure; 2)lifelonglearningand conSuing medicaleducation:3) cognitive assessrnent 4) practice perlömsanceassessmentand improvcmenq and 5) continuousAOAmembership.Scenestates have begun to accept 0CC, or the relatedMaintenanceof Certification(MOQ, requirements as dccepnble laplace of CME requirements.

Malpracticeinsurance - Infootation regardingthe state requirements for and availabilityof malpracticeinsurancecoverage has been provided by some states.For infomndon about specificinsurance carriers,contact the divisionalosteopathicsocietyin the appropriate state.

Those interested in additional information about states’ licensing requirements may contact the individual licensing boards or AOA’s Director of State Government Affairs, 142East Ontario, Chicago IL 606fl (800)-621.1773ext 8185.

2 STh2 REOUTREMEWrS

ALABAMA EducationalReqoiremenn:Graduation from osteopathic collegeapproved bymedicalboard PostgraduateTrniningtI yearof approvedAOA orACGME trainingfor graduatesof accreditedschools;3 years for graduatesof schools not accredited Pnarth 15 ?.Ds BoardAddztss:AlabamaBoardof MedicalExaminers,Sarah H. Moore,ExecutiveSecretary,848WashingtonAvenue Montgomery,AL 36101-0946Phone (334)2424116 or (800)227-2606Fax @) 242-4155 OsteopathicMember:GaiyK Hill,DO Website;zm&ilreorg SnnzUapt Yes ExamiaptiontAccepted:COMLEX,NBOMEJ USMLE FLEX, NBME, state examinationsadministeredbefore FLEX (exceptFlorida& Puerto Rico) license Pea:$75;apphbon fee -$175; applicationpacket - $20; criminalbackgroundcheck - $65 (total fee - $335) FederationCredentialsVei*icafionService(FCVS: Willaccept Endnn.ment: SPElLexaminationrequired if applicant has nor passed a written certificationexam far liccnsure or has not been Board certifiedor re-certifiedbyan ADA oran ABMSmember within the list I0 years. SpecialLicenses:No temporarypermits Re-rc4stnizion:Annu2l, byDecember31 - $360;Effective May 25,2012, gracçperiod (January1 thmughjsnuaxy 31) additional $100fee C?sffiRequirements:25 houseof CategoryI everyyeas;OCC/MOC not acceptedas a substitute MalpracticeTnsunnce: Not required

ALASKA - EonatRequiremmt Graduation from osteopathic collegeapproved by statemedicalboard Pnstnduate Tnininp: 1 yearin ADA or AMA approved hospital if graduatedprior tojanuary 1,1995; 2 years if the graduation dazeis afterjansnç7 1,1995; &azrl:Sphytidans,2 publicmembers)I PA BoardAddress:AlaskaSkateMedicalBoard, Dcbon Scovem,Executive A&ninistnror, State Medial Board, 550 West SeventhAvenue — Suite 1500,Anchorage,AK 99501. Phone (907)269-8163Fax @07)269-8196 Osteopatf.ieMembernSal-tAngIJu, DOJoy M. Neyhart, DO Website:ww.commcrtealaskaenv/web/cbpl/PmfessionalLicensLg/StiteMcdks1Boardsspx Sunset Law,Yes Fnminadons Accepted: COMLE NBOME USMLE,FLEX Other Reodrnnenrr In person interviewrequested at the discretionol the Board LicenseP: $300;applicationfee - $200 (total fee - $500) Feilention CredentialsVerificationServiceiFCVS):accepts Reciprocityor Rndorsement:SPElLmay be rcquimd Snecialricemen Temporarypermit until board meets to consider endorsementapplication,$75;LocumTenens pemilt to substitutefar Alaskanphysician,$100 + $100non-refundableapplicationfee flnewa1: Biennial,Decethber 31 of even numbered years - active - $300;inactive- $125 CME Requirements:Require25hours in ADA orM.!A Category I per year; (OCC/MOCnot acceptedas substitute) and at last two (2) hours must be devoted to pain managementand opiold use and addiction. IdalLlracdcetocurance: Notsequired

ARIZONA EducationalRequirements:Graduation from an AOA approved collegeof osteopathicmedicine. PostaraduateTninhig I yearapproved byAOA orACGME :a,itri: 5 DOs, 2 public members DudA4dwn: Añoua Board of Osteopathic Examinersin Medicineand Surgeq,Justin Bohali,ExecutiveDIrector, 1740W. Adams SLreeçSuite2410, Phoenix,Al 55007Phone (480)657-7703Fax (480)657-7715 Ostenoarhic Members:Douglas Cunringbm, DO; MartinB, Rdss, DO; Christopher Spie&emsan,DO; Gary Erbstoesser DO;josiathan Maitem,DO Wnbsitegs - SunsetLaw, Yes ExaminationsAcceptcdt COMLEZ NBOME, US?vflE,FLEX (75%or better on both components) LicenseFe: application fee- $400plus pro-rated licensurefee Federation CredentialsVerificationService(PCVS’IttQfllaccept Rtcipmchy or Eadonemenu Athon, allowsdoctors to be licensed basedon “continuouspractice”.Ifs physicianpassed the licensing exammorethan 7 yearsagoand has been in advanced training(residencyor fellowship)orin practicecontinuouslyftom the dateof first liomsure State, cansubsthtte “continuous in any the physician practice” for havingrecent n scores.The same application formisused. Personalinterviewmaybe required;interviewgivenintemilnenUy.

3 -

Speciillicenses. Temporarylicense — Na ice at this time.Musthaveappliedfor a Ml license.Expires250 daysafter issuedor on approvalor denialof a Ml license;Acceptappicafionsfor the InterstateMedicalUcensureCompact;LocumTenens issued (cr90 thy period- 30O; can be renewedonce for another90thys - $300;EducationTeachingPesnir $318;TrainingPermitfor individualsin accreditedinternship,residencyor clinicalfellowshiptrainingprograms- $50;ShortTerm Permitfor individualsin accreditedinternship, residencyor clinicalfellowshiptrainingprogramsin Arizona for the purposeof CME - $50. RenewabFiat yearon December31,thejeafiereveryZycan from date of licenseissuanceon or beforeJanuary 1st-$636 CMSRequirements:Arizonarequiresthatlicenseesreceive40hours of CMEdutingthe two proceedingycarfleforc the licensingrenewal datc,whichmust includat least24hours of catcgoiyIA ACM CMEor that licenseehasparticipatedin an approvedinternship,residency,

or fellowship;OCC/MOC not acceptednssubzdmte. - Malpracticeinsurance: Not required

ARKANSAS EducationalReaufremcstrs:Graduation from an AOA approved college PostgraduateTmining 1yearin anAOA orACGME accreditedprogram •9azd 11MUs, I DO, 2 publicmembers , Rnani Address:ArkansasSestcMcdicalBoard,ArnyEmbry,InterimExecutiveDirector,VictoryThifliding,i401 West CapitolAvenue, Suite540,little Rock,AR 72201Phone (501)2%-1802 Fax (501)296.1805 Osteopathic Member: Vcryl1). Hodges, DO ‘X’ebsite:;nvwmedkalhoard,ora

Sunct Law:No - Exanltndons Accepted; COtQEEX,NBOME, USMLE,FLEX, NEME, State Board exam takenprior to 1975 Other Requiranerits: Criminalbackground checks license Pee: application fee - $400;CCVSfee - $100(total fee - $50; temporarypermit fee alsorequired - $50 Federation CredentialsVerificationService(FCVSbYes. - Redpmdry or F.ndorsemen;,No SpecialLicenses:Temporary pennic can be issuedafter everydetailof the applicationprocess has been completedand is readyfar Board approa,L Temporary Peanits must be requested in writingvnth required lee -$50 Renewal:EffectiveJanuary 2014:Annual -$220, due in month of birth. Licenseexpireson the lastday o(the applicant’sbirth month. CME Reriuirements:20 credithours of AOA or AMA Category 1 0z2 per year;10bows must be Category I and in the area of the physidan’sprimarypractice;OCC/MOC not accepted as substitute;but bournare granted ior time spent in preparation for specialtyboard certificationor rcccrtiflcationexamination tiNpnctic fqsuranc: Not required

CALIFORNIA

EducationalRequirements:Graduation from an AOA and CaliforniaBoard approved college - PosteraduateTmininw 1 yearapproved byAOA orACGME, which Includesat least4 months of directpatient care medicinein an approvedpostgraduate trainingprogram. EffectiveJanuary 1,2020—36 months of AOA or ACGME accreditedtraining.At least24 consecutivemonths axerequiredin the same trainingprogram. However,if an applicant has satisfactorilycompleted at least,1year of approved postgraduatetraining,is certifiedby a specialtyband authorizedby the AOA or approved by the Amedcan Board of MedicalSpecialtiesand has held an unlimitedlicenseas a physicianand surgeonin another state(s)for a period of 4 yearsor more, not includingany timespent in approved postgraduate training,be or she may be eligiblefar licensure. - Basic ScienceBond: Yes axili 5 00s,4 public members RbVd Address:Osteopathic MedicalBoard of Cahfoma, MarkM. Ito, ExecutiveDirector, l300Natianal Drive, Suite 150,Ssaimenro, CA 95834-1991Phone (9I 928-6390Fn 1Ø 928-8392 OsteopathicMembers: C3msBuha4 ElizabethJcnsen-Bhambcrg,DO;Joscph Zanvacto, DO

Webcitt www.cmbc.a.gov/ . .

SMnsalIanc Yes - Exa,mnauons Accepted; COML.EXLevels 1-3 and Performance E,luation (PB)completed and passed; C0?’IEC: Levels I &2 pius FLEX COMV or an equivalentstate written exam that tests ior osteopathic pdndp!es. Other Requirement: Applicantsshould aDow16weeks for fingerprintcard to dear proper channels. LicenseSee:applicadoh fee - $200;fingerprintcheck fee -$49 (total fee - $249) FederationCredentialsVerificationServicetFfl!: Willaccept Reciprocityor Endorsement: No reciprocityor endorsement vAthany other state. SpecialLicensee:Effective January 1,2020, a Postgraduate Traininglicense (PTL)willbe required for allresidents participatingin an AOA orACGME accreditedpostgraduatetrainingprogram in Californiain order to practice medidne as pad of their trainingprogram.A PU mtntbe obtainedwftliln lEOday, afterenroilmentia the program and willnotbc requiredtobe renewed.The prolil: cia holder cfaPTL willbe displayedon the Board’swabahefor public view. Any residentparticipatingin an accreditedpostgraduate trainingprogram at the timethe lawgoes in effect, and who is not eligiblef foil physicianUcensure(requires completionof 36 months of postgraduate training,24 consecutivemonths of’wttichmust be completedin a singletrainingprogram), willneed a Pfl. byJune 30, 2020, to continue in the program. Applicantsmayapply fcctheir 711 as soon as they

4 -

havegraduatedfrom osteopathicmedicalschool,ompleted COMLECLevelI and 2 and receivedcon5nndon of acceptanceintoan

ADA orACGME accreditedCaliforniaprogram. - The PflJs validfor a (nonrenewable)period of 39 months,whichincludesa90 daygraceperiodfollowingcompletionof 36 months of postgraduatetraining, duringwhich time residents must obtain a Ml licensein order to continue in theirprogram. Renewal:Biennialrenewableeveryother year in the applicont’sbirth month (evenbirth month i.e.Febnusy, April,June, etc... renewin even year andodd birth month ic. January,March, May,etc. .renew in odd yen); Active - $400 CME Requirements:Each licensedosteopathic physicianand surgeon shallcompletea minimumof 100 hours of ADA continuing education hours duringeachtwoyearcycle,of which 40 hours must be completedinAOA Category IA or lB continuingeducationhours ass condition for renewalof an activelicense.In addition, all physiciansmust complete a one-timerequirementof 12hours of CZffi in subjects of painnanagcment and the treatmentof terminallyilland dyingpatientswithin4 yearsof beinglicensedor by the 2nd renewal whicheveroccurs first.Pathologyand Radiologyspecialistsare exempt If the CMISis listed on the certificateas AMA,it will count as ADA Category2. OCC/MOC not accepted as substitute. In addition, physicianstiny receive .5 units of Category2 CME for each individualjournal read. MalpracticeTnsurmiee:Not required.However, a physicianis required to carryliabilityinsurance in an outpatient surgery setthsgpursuant to Busmessand ProfessionsCode section 2216.2.A physicianmust also followthe reporting requirements cited in Business and

Professions Code section 802in regard to lawsuitsettlements antj arhitsationawards. -

COLORADO dutional Requirements:Qndñadon from arecognized osrccpathic college PocrendsrateTmining I yearin a hospital approved by theAOA or ACGME ad BMD; 3 DOs, I PA-C,and 4 Public Members Board Address: Colorado MedicalBoard, PaulaThMnrtina, Program Director, 1560Broadway.Suite 1300,Denver, CO E0202Phone @03)894—7600Fax (303)894-7692 Osteopathic Members: Donna M.Bsldvtin, DO; Teresa K Braden, DO; ScottStrauss,DO

- thsitz https://wwwcoloradnfov/nad&/dorilMedkal Board Sunset Lat Yes ExaminationsAccepted: COr.U,EX NBOME, USMLE,FLEX, State Examinationsand LMCC license Fee: $412 Federation CredentialsVerificationService (FCVS: Willaccept Reciprocityor Endorsement: Endorsement Sperriatticernes: PhysicianTraininglicense Renewal:Biennialodd numberyears.April 30- $140 + $250 = $390 (RenewalFee subject en change) CME Requirements:None MalpracticeInsurance: Insurancecompaniesthat writemalpractice insurancein Colorado are required to report allsettlements or judgments againstphysicianslicensed bythe state. Physicianspracticingmedicinein Colorado must meet financialresponsibilitystandards in the amount of $1,000,000per incident and $3,000,000annual aggregateper year.

CONNECTICUT Educational Requirements:Graduated with the MD or DO degree &oma medicalschool accreditedby the LCME orthe ADA PostgraçhipteTraining Completedat least2 yearsof progressive,post graduatemedicaltrainingas a residentphysicianin a program accreditedby theACGME or theAQA flmx±12MDs, 1 DO, 1P47 publicmembers BoaxdAddress:Connedoit MedicalExaminingBoard,Jeffrey Kardys,AdministrativeHearings SpecialistBoard liaison, 410 CapitolAve., MS#13PH0, P.O. Box 4030B, Hartford, CT 06134Phone (86 509-764RFax @60)509-7553.Examinationand Uca,sum, Stephen Carragher,Public Health ServicesManager,410 CapitolAye, 12 APP, Hartford, CF 06134-0308-PEone(860)509-7590. Osteopathic Member;AndrewYuan,DO; MarieEugene, DO www.ctgov/dph - SunsetLaw:Yes Examhntions Accepterl:NEOME, USlvff.E,FLEX, NBME, LMCC, state boardlicensingexambeforeJune 1, 1979 license Fee:$565 - FederationCredentialsVerificationService(FCVS Willaccept Reciprndtv or Endorsement None - SpecialLicenses:None Renewal:jjinuaUy, the firstbirth month followingissuance.Renewalbe - $570 reinstatementfee -$565 CME Requirementu A licensedphysicianshall eain a minimumof 50 contact hours of qualifyingcontinuingmedicaleducation every2 years commencing on the first dateof licensetenev,a1 I contact hour mcan a minimum of 50 minutes of continuingeducationactivity.Once every 6 tears, I CMI! hour heath of the followingtopics:(A)Infectious diseases,including but not limitedto, acquiredimmune deficiency syndrome and human immuoodeficiencyvirus, (B)risk management, (Qsexualassault, (D) domestic violence,(B)culturalcompetency,and 0 behvioral health.Beg{nnlngJanuaq 1,2020, such behavioralhealth CME must include at least 2 contacthours on 4iagnosingand treating cognitiveconditions, not limited Q) induding,but to,Mzheimer’sdisease,demcnda,delirium,relatedcognitiveimpairmentsand geriatric - depression,or fu)mentalhealth-conditions,Including,but not limited en,those common to veterans and &mllymembers of veteranssuchas post-tnumadce stress,riskof suicide,depressionand grief. OCC/MOC not accepted as substitute.

S Malracdce Insurance: Each DO licensed to practice osteopathic medicinethat provides direct patient care servicesshall maintain professional liabilityinsurance or other indemnit against liabilityicr malpractice.The insurance must be no lessthan $500,000kr one person, per occuerence,with an aggregateof not less than$1,500,000. -

DElAWARE EducationalRequirements:Graduation from an AOA or AMA approvedmedicalschool PostgraduateTnining 1yearin an AOA or AMA approvedhospital; if fordg-n-taind, 3yearsis required mxsk 7 MDs, 2 DOs (mustinclude at last I DO), 7 public members Band Address:DelawareBoard of Medial Iicensme and Discipline,Devashree Singh.ExecutiveDirector, Cannon Building,861 Silver

•Lake Blvd.,Suite 203,DoVer,DI! 19904Phone (302)744-4500 Fax @02)739-2711 OcteOpRth Member Joseph M. Pathe, DO; Barry L. BaIts; DO Website:www.dptdelawaregov Sunset Law:Yes Examinations Accepted:COMLEX, NBOME, USMLE, FLEX, stateexaminationstaken prior tojanuary, 1973 Other Rcquirr.ments:Recommendadop from Chief cfStaff, verificationof Ucensurein good standing on alllicenses,and self-queryfrom the NPDB and HWDB, and criminal backgroundchecit.Also required,scrviccletters at eachfacilityfor the past 3 7ears;and sex offender and adultabuseregistries. LisanstE: $354 Federation Cr dentialsVedfndon Service(Ffl’S): Willaccept Reciprocityor Endoncrocot: No SpciaLicsnm: No Kta&nl: Biennial,renewalbyMarch 31 everyodd year MEcquiuianw40 hours every2 years - must be CategoryI AMAorAOA; OCC/MOC not accepted as substitute MalpracticeInsurance:Statela

DISTRICT OF COLUMBIA FAucationnlRequirements:The equivalentof 4 years of instruction and trainingat a schoolwhichis leg-allychartered or organhed in the United Statesor Canada and .vasaccreditedat the time of the applicant’sgraduation by the LiaisonComthittee on MedicalEducation. (LCM of the AmericanMedicalAssociation(AMA),the AmericanOsteopathic Association (AOA),or the Committeeon the Accreditation of CanadianMedicalSchools.Applicants must be in receiptof the degree of MD or DO Postgnduate Trainlnr AUpostgraduate clinicaltrainingmust be at a hospitalor health tate facilitylicensedin the UnitedStatesin a program accreditedby theArczedimdon Council for GraduateMedicalEducation (ACGMJ or the American OstenpathicAssociation jAOA) or in Canadaaccreditedbythe LMCC. US MedicalGraduates:AllUSmedical school graduates mustcompkce one year of postgraduatetrainingto be cligiblcforMI licensure. Foreign MedicalGraduates:All foreignmedialschool graduatesmustcompletethreeyeiixsof postgraduatetrainingto be eligiblefor fUll licensure. En: The Board,currentlybystatute,shallbe composedof no morethan fifteen(1 manbers appointedby the Mayorwith the advice and consentof the Council.Ten (10)membersmust be licensedphysiciansin the Districtof Columbia,four (4)shallbe consumer members, and one (1)membermust be the Directorof the Departmentof Health or his/her designee. There are currently11membersserving on the Board-6 physicianmembers,I Department Designee,and4 consumermembers. The Board meetsthe lastWednesdayof everymonth unlessnoted otherwise. Board Address:DistrictofColumbiaBoard of Medicine,FrankB.Meyers,JD,ExecutiveDirector,899North CapiroiStreet,NE, 1” Floor,Washington.DC 2000Z Phone (202)7244900 Fax 02) 442-8117. Qpathic Member;None Website; http:fldoh.dc.ncvlbomed SmacxJaNo Examinations Accepted:COMIS NBOME, NBME, USMLE, FLEX LMCC Other Re9uirementstBeginning2010new applicantsfor a healthcarelicense,registration or certificationin the District of Columbiawill be required to undergo a criminalbackground check as pan of the licensmeprocess. Adverse information ‘ill be reviewedby the Disticeof ColumbiaBoard of Medicinefor professions fallingunder the Board’spurview. license Pee:applicationandlicensingfee - $805;rthiewalfee - $500 Federation CredentialsVerificationService (FCVS):Willaccept ReciprocityocEndnmement: No reciprocityor endorsement applicantsmayapply by“waiver of examination”if an acceptedexam was successfUllycompleted. SpecialLicensa: No temporarypermits, a postgraduate physicianmaypracticemedicine in a clinicaltrainingprogram approved by the AOA, ACGME, or the Boat MedicalTrainingLicense for residentsand IeUowsin trainingis currentlyunder congressionalreviewand the anticipated DC lawdate i5March 21,2012. The Board doesofferlicensurebyeminence.This providesa differentpathwayfor practitionerswho ate of eminentqualificationsfrom a foreigncountyand whowouldnot meçt normallicensurerequirements(e.g..passageof exam,thee (3)yearsof ACGMEtraining,etc.). Renewal:Biennial(evenyears),December31-$500 OLE Renuirements:Physicianswithan activeDC licenseshallsubmitproo( I havingcompletedfifty(50 AmericanMedicalAssocladon

6 —

PhysicianRecognitionAward (AMA/PItA) Category I or CategoryI-equivalenthours,Hut includesthe completionof two (2)hours in culturalcompetenceor appropriateclinicaltreatmentspecificallyfarindMduals who are lesbian, gay,bisexual,tansgender, gender nonconforming, queer, or questioningtheir sexual orienthtion or genderidendfi and expression (LGB’JVJ. Malpracticelninnce: Not required

FLORIDA Educational Reauizements:Graduation from an AOA accreditedcollege PostgraduateTraining:I yar ADA approved rotating first year.Any applicantwho has not completed an AOA approved internship must apply to the AGA (or approval of fltst year of the ACGME residn for educationalequivalence.If the AOA approves the ACGME residency’sfintyar for educationalequivalencyand denies the destonstsadon of good ou,c for having taken the ACGIt!E residency, the Florida Board of OsteopathicMedicineshall reviewthe applicant’sdemonstration of good cause. flat 5 DOs, 2 public members aziMán: florida Baird of Osteopathic Medicine,KarmaMoaroc,JD, ExecutiveDirector, 4052 Bald CypressWay,RN #C-06, Tallahassee,Ft 32399Phone (S5( 245-41ó1Fax (85( 921-6184 Osteopathic Men,he thefle Mendea,DO;jod Ease, DO; Santin Scbwemmer,DO; Anna Hayden DO; BridgetBellingar,DO Website wwwfloridasosiropathintedicine.gov

Sunset Law No - - Exaaioasicna Accwd: COMISc NBOME, COMVSC, state board exam t&rStqukvmenrs: Fingerprints— Fee to be detemilned (Each Uvescan vendor chargesdifferent amounts toethis service.) Licer,AcFera$305plus applicationfee - 52W (total fee - $505) - Federation CrrdcntialsVerificationSersice (FCVrn:Yes, stronglyrecommended SpecialIienUnthed and Faarln; Area of CriticalNeed; OsteopathicExpect Witness Renewal,Biennial,March31 everyeven year,Active -$429 (andif licaised bekre 1/1/2013 $405);bucthe -$229 (and it licensedbefore 1/1/2013 $205) CHE Requirements:40 hours biesmiafly;20 hours must be bOA Category1-A relating to the practice of osrcdpathicmedicine or under osteopathic ausplces. The following three 04E aedia must be obtain via live,participatorycourses: 1 hour In FloridaLaws and Roles/Professional and MedicalEthic, and 2 hours in Prevention of MedicalErrors. In addition, licenseesmust complete a 2 hour Domestic ViolenceCourse as part of everyIbid biennialrenewal;a cg,-flm,1 hour HW/MDS course no inter than upon the first biennial renewal;and licenseeswho are registeredwith the US DEA and authorized to prescribe controlled subarea must complete a 2 hour course on prescribingcontrolledsubstancesat.eath hiennialrenewalof licensure.The aforemennond 5 CME hoursmay be completed in a distance learningfomiat (seeEAt. Chapter 64I 5-13 for detailedrequirementsand approved CME course providers). For fellows,interns and residentsin approved bOA, AW or ACGME educationaltrainingprograms, 10CME credit horns shah be awarded for succersfiilcompletionof each 6-month training prognm period. 0CC/MOO not accepted as substitute. Maipxasricefr,surancc Must airy at least $100,000in malpracticecoverageto practice medicine,and must any $250,000Li malpractice coverage to have hospitalprivileges.Allows for no malpracticeinsuranceif the physicianposts a signin his or her office indicatingto patients that he or she does not carrymedicalmalpracticeinsurance.

GEORGIA Eductional Requirements:Graduationfrom an osteopathic collegein good standingth the bond Postgraduate Thirthig 1yearbOA or ACGME approved postgraduateinternship/residency trahdng n± 11MDs,200,2 coma members, I Ba-Officio rhentha Board Address:GenrgiaCompositeState Board, LaSham Hughes,MBA,Executive Director, 2 Peachtree Stttet, NW, G’ Fbor,AUanra, GA 30303Phone (404)636.3913Fax (404)656-9723 3swsth&Mmthsn: flashy3.Sirmuens,DO Web www.medicalboard.gecrpj&ov Sunset Law No nmin,dons Accepted:COMLEZçNBOME, US!aE, FLEJçLMCc, STATEBOARD,NBME license lee: Initial& reinstatementfee - 5500; renewal fee - $230 Federation CredentialsVerificationServicemn’ Willaccept Redprncity or Endorsement: No, must start at the beginning of the process Speciallicenses: Teacher’slicense - $300;Institutional physicianrenewal - $60; provisionalphysicianrenewal - $50 Renewal:Biennial,$230.Al]activelicensesmust be renewed everytwoynrs, by the last day of the month in whichthe appEcant’sbirthday Calls,based on initial licensure;late fee-$455for 3 months after birthmonth Qiccnserevoked fbr non-renewalaer 3 months CME Reouirwnenn:40 houm over2 years of bOA Category I orAl,&ACategoryI, AAFP Prescribed Credit,ACOG CategoryI or ACE!’ Categocy1. 0CC/blOC not acceptedas substitute. For physicianswho do nochold a certificationin psi4imanagementor palliative medicine, and whose opiold pain managemetirpatients comprise50%or more of the patient population, 20 of the above houra must pertain to pan managementor palliativemedicine. EffectiveJanuary 1,2018, everyphysiciannot subject to the aforementioned requirement who maintainsan activeBRA certificate and prescribescontrolled substancra, ccccpt those holdings residencytrak’ing pemilt, thall completeat leastone time three or more hours of AMA/bOA Category I CME that is designed specificallyto address controlled substancepresaibing practices.The controlled substasiceprescribingCMBshallinclude instruction on controlledsubstance prescribing guidelines,recognizingsignsof the abuse or misuseof controlled substances,and concrollcdsubstanceprescdbin forchronic

. 7

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pain managranentAny controlledsubstances pzcscdbingguidelinescounework takenwithintwo yenta of the physician’slast renewalwill count towardthis requirement.Completion of this requirementmay count as threehours towardthe CZffirequirementkricense renewal MalpracticeTnsunnce:Not required by state law, but physiciansmust discloseto the public if they do not earaymalpracticeinsurance.

HAWAII EducstlotiaiReçuirements:Graduation from an AOA approved college Emlgraduate Training:1 yearinternship in AOA approved trainingpiograna,ACGME accredited trainingprogram, Canadian haloing program aecre&tcdby RoyalCollegeof Physiciansand Surgeonsof Canada or the Collegeof FamilyPhysiciansof Canada. gg 7 MDs, 2 DOs, 2 publicmembers Bond Address:HawaiiMedicalBoard,s\h]ajil K Quiugue,Executive Offcer, Department of Commerce and ConsumerAfFain, 335 lkrchant Street,Room 301 Honolulu, RI Pó8OlPhonr (8D 586-2699Fax (80 586-26B9 Osteopathic Members: Michael3.1k, 0OJone Gdmer.Flanden, DO Websirt: cra.hnwalirnv/pvl /hnards/mrdical Sunset T.asv,No E,n,inarions Accepted:COMLEX,NEOME, USMIS, FLEX Lkrns2rs: $510licensedJuly 1 even-numbered yeartojune 30 odd-numbered yesr / $384Ju1y1 odd-numberedyear wjune 30 even- numbered year. Federation CredentialsVdficadoñ SeMce (FCVSI:Willaccept Redprodty or Ppdn,ement: No; however, proposed leajsladonto allow icr licaisose by endorsement Ismaltingihway through the Jegisladvcpnxess (as of 3/21/1. SpecialTiccnscs:Board canissue temporat)’licenses to osteopathicraidenu. RenewaLBiennial,June, evennumbered years - $312 (on dme)4392 ste) CME Requirements:Corrwkte48 Category I or IA CME hours duringeach 2 yearlicensingcycle (evenyn). OCC/MOC not accepted as substitute. Malpracticelnsuranr Not required

IDAHO Educational Reqdrernets: Graduation froenan AQA approvedcollege Postnduare Tnininr tyrar in an AOA or AMA hoapitalapprovcd for intcmthips — for US graduates U2nth 5 MDs, 1DO, 2 publicmembers and the Director of Idaho StatePolice Board Address: Idaho Bond of Medicine,Anne K LawleaJO, RN. Executive Director1345 Bobwhite a, Suite150, Boise, 1083706 Phone (205)327-7000Fax(2O 327-7005. Osteopathic Member MarkGnjcar, DO Wehite: born,ldaho.gov Sunset bvn No Fnnilnadons Accepted:CO?.LEX, NBOME, USMLS, FLS OtherRequirements: Tnter&wmaybe required License Fee:$500 Federation CredentialsVerificationSen*eJPCVSh trn accept Reciprocityor Endorsement:An expedited method of obtainingMl physicianlicenswe in Idaho that isavailablewall physicianswho meet the LicensureEndorsement dtrth, Section 53. Endonernenris nt a tempcrsry licenseprocess nor is it redprodty SpecialLicenses:None / Renewal:Annual - $250;Inactive- $100 CME Requirtmans: 40 houn practice rekvant to CategoryI every2 years. OCC/MOC not mendan&l, but the Board accepts certification or rectstication with a board 61the ABMS,AOl., or RCPSCin lieu of compliancewith Qu! requirements. MalpracticeInsurance: Not required ilLINOIS Educational Rec&rernenrs:Sstisfacroq completion of 6 yearpost-secondarycourse of study consistingof 2 academicyear! eta count of instructon in a collegeor universityand 4 academic yearsof medicaleducation from a medical or osteopathiccollegeaccredited by the Liaison Committee on MedicalEducation or the AmericanOsteopathic Bureau on Professional Education. Pnsrgnduate Tninin 12months in hospital approved bystate if applicant is a graduate of a medicalor osteopathicco11egcin the United States; 24 montlu if applicantis a graduate of a medics! collegeoutside of the United States. IllinoisMedicalLicensingBoard: 5 MDs, I DO, I DC. DisciplinaryBoard:5 MOs, I DC, 2 publlcmembers. Board Address:finn S.Zachariah,MD, MBA, Chief MedicalCoordinator, 320W-Washington, 3’ floor, Springfield,IL 62786Phone (217) 524-7534Fax (217)524-2169 Websiet www.idfpr.com Osteopathic Member NicholasParse, DO; Karen O’Mara,DO SuncerLaw:Yes Ennunstinns: NBOME, USMLE,FLEX, LMCC, SPEC, COMVEX License Fee: fefort July 1,2818, fccis $700.BcgnningJtily 1,2018,1cc is $500. Federation CredentialsValEcationStroke (FCVs: Willaccept

- 8 £gjpmdty or Enslnnemenr: Applicant must be currentlylicensedto practicemedicinein allof its branches in another jurisdiction. Applicants consideredon individualbasis - PanS of USMLE mayhe required if not certifledbyanAmericanspecialtyboard,received specialhonors or awards,had articlespublishedin reputable journals,orpanicipated in the writingof textbooks on medicine.Interview and/orSPEXor COMVEXnny be required. SpecialLicenses,Temporarycertificatesforresidency trainingprograms - $3O; visitingphytithns - $100 visitingprofessors- $300.An inactivecategoryfor retired or otherwisenon-practicingphysicianswhich contains provisions for reinstatanent to active standing. RenewaLLicensesexpireeverytince years frocajidy 31”, 1990.(Enmple:July 31” on the years2017,2020,2023 etc.)-Beginningjuly 1, 2018,feeis $501for three years Cm-stateresident);and $750 for three years (non-resident) CME Requirement:licensees are required to complete a total of 15(1hoursper prerenewal period. A minimum of 60 hours of the total requiredhours shouldbe obtainedin form,] CMEprograms;theremaining90houresbIl be obtainedin inrmal CMEprograms activities.OCC/MOC not accepted as substitute. 1hour of sexualharassmentprevention is required for all physiciansin order to renew a license.For physiciansrenewinga controlled substance license,3 hours of safe opioidpresctibing education is alsorequired. Allphysicians renewingthis licensewillneed to complete the opiold prescribingeducation offered or accreditedbya state government agency,federal government agencyor i prokssional associationprior to renewal (no later thanJuly 31,2020). MalpncsiceInsurance:Availablethroughcommercialcarriers.

INDIANA - EducationalRetpijrementa:Diploma and transcript from recognizedcollege Postgnchiate tnine 1year,prior to licensure.AOA or ACG.E approved;2 years for graduatesof foreign medicalschools. Enaial 5 MDs, 1DO1I public member Board Address:MedicalLicensingBoard of indiana, Daaen It Covington,JD, Board Director, 402W. Washington Street,Room W072. Indianapolis,IN 46204Phone (317)234-2060Fax @17)233-4236 itji.cMemhrt: KirkMasten, DO Website:www.innov/ph /medicol.htm Surnet Law,No ExaminmionsAccepted:COZVUIX,NEOME, USMLE, FLEX LicenseFeet $250

Federation CredentialsVerificationService(FCV1: Willaccept - Reciprocityor F.ndorsemc,t By endorsement on the basis of unlimitedlicense,if equivalentto Indiana exam or passingNadooal Boards. personalinterviewand/or SPEX may be required. Spedal Licenses:TemporaryMedicalPermit (flil’) fix postdoctoral training-$100; renewalfee - $50 Renewal:Biennial,October 31, odd years - $200 CMR Reintiretnents:BeginningJuly 1,20191each physicianor osteopathicphysicianapplyingfor orrenewing their controlled substances registrationill need to havecompleted two (2)hours of continuingeducationin the topic of opioidprescribing and opioid abuse during the previous two (2)years.A list of approved continuing educationorganizationscan be found at https://www,jcjgov/nla/4040.htm. Malpracticelnsuiunce:Not required

IOWA Educational Requirements:Diploma issuedafter May 10, 1963,bycollegesof &teopathlc medicineand surgeryapproved by the Board, or equivalenteducationapproved by the Boad. Those with diplomasissued before May 10, 1963,should write to the Board.

PostgraduateTraining:I yearin post graduatetrainingprogram approved by the Board (2 years for Th{G’ronly) - listdi SMOs, 2 DOs, 3 public members Board Address:Iowa Board of Medicine,Kent Neb4 Executive Director, 400 SW. 8° Street,SuiteC, Des Moines,IA, 503094686 Phone (515)281-7088Fax (515)281-8641,[email protected] Ostecpathic Members:BrianWilson, DO Websfte: www.nedicalbo,rdjovn,gov Subset Law,No

ExaminationsAccented:COMLEX, NBOME, US?VE.E,FLEX, UwICC - Pem,apenr LicenseFee $495 Federation Credential,VerificationService(FCVS’:Willaccept1but not required Redarocity or EMorae,nent, Applicants who meet the eligibilityrequirementsfor permanent licaisure may qualifyfor expedited endorsement if theymeet allof the followingrequirements: • Hold at leastone permanent U.S.state/jurisdiction or Canadiannedic.al license • Hold an unrestrictedlicensein everyjurisdictionin which the applicantis licensed • Havc no formaldisciplinaryactions or activeor pending investitions by a board, licensingauthority,medicalsociety, professionalsociety,hospital, medicalschool, federalagency,or institution staff sanction, in any state, county or jurisdiction • Hold current specialtyboard certificationbyan AOA or ABMSspecialtyboard - lifetime certificationis excluded a Have been in continuous activeprachce during thepast fiveyears - time spent in post-graduatetrainingis not considered continuous adve practice Applicants who meet thesecriteria are not required to submit the certificationof medical education,medicaleducationtranscript,copy of diploma,vvd5cadonof post-graduate trainingor ECFMG StatusReport in theapplicationprocess. A veteran with an unrestrictedprofessionallicenseinanotherjurisdiction,who does not meet the licensurerequirementsin Iowa, may

9 apply forlicensurein Iowathroughreciprocity.A militaryserviceapplicantmayapplyfor creditfoeverifiedmffitsq education, training.Or servicetowardany experienceor educationalrequirementfor liccnsurcby submittinga militaryserviceapplicationform to the hoard office.A veteran or rnEirazyserviceapplicant mustpass any examinationsrequired for liceosmeto be eligiblefor licensure thrwgh - reciprocity.A hilly completedapplication for UcensuresubmittedunderthIssub-nilebya veteran or militaryserviceapplicantshallbe gies1priorityand shallbe expedited(effective1/28/13). Iowajoined the InterstateMedicalJicennire Compact onJuly 2,2015. The Compactoffers a at’s’,voluntaryexpeditedpathwayto Ucensurefor qualifiedphysicianswho wishto practiceIn multiplememberstates. InterstateMedicalUceniure FAQs, an rmeracuve Map, News and more can be found on the kteatate McdicaiLicensurc Compact pagc wwwirnkcorg (effectiveApt] 2011). Qrher licenses: AdministsativaMedicinekense, $405,issued to adviseorganizations,both publicand private, on health cart matters;autho±e and deny financialpayments for carc organizeand directresearchprograms;reviewcareprovided foe quality;nd other similar duties that do not require direct patient care.Admhthtntive medicine dots not includethe authority to practice clinicalmedidnç examine,care for or tent patients, prescribemediations including controlled substances,or delegate medicalacts or prescriptive authority to others. • Resident physician’slicense,$145,issuedfor practice in an Iowa program approved for residency training

O Temporary license,$145,issued for Board approved.activities. . Speciallicense,$345,issuedto a physicianwho is an academicstaff member of a collegeof medicine if that physiciandoes not meet the qualificationsfor apermanent license.The physicianshould be held in higiiesteem for unique contributions theyhave made to medicine,and willmake by practicingin Ion Renewthflicnrial, first licensccan be issued for a shorter period oEthne in aider to get the license expiration date into the birth month and year cycle.A physicianborn in an evenyear willhave a licensetint expires on the first dayof the physician’sbirth month in even years. Simihriya physicianham on an odd year.RenewalFee - $450online;$550paper. Exemption to the permanent Ucennirerenewal fee for physicianson Mi-time dutyin USArmed Forces, Reservesor National Guard (effective8/25/13). DuE Requirement:40 hours ofAOA orA?.IA CategoryI required biennially,which include trainingfor identifyingarid reporting abuse, chronic pain management and end-of-life cam For licenseewho regularlyprovides primaryhealth care to chIldren:2 horns of trainingin childabuseidentificationand reporting in the previous5 years;for a licenseewho regularlyprovidespdmaq health are to adults: 2 hours of trainingin dependent adultabusèidcntifiation and reportingin the previous 5 years.For licensee-whoregularlyprovides primaryhealth care to adults and children:separatecourses o(2 hours each as outlined before or a combined 2 hour course that includescudeuk for identifyingend reporting child abuse and dependent adultabuse. Iowa-licensedphysiciansare required to complete 2 hours oICategory I activityfor chronic pain managementand 2 hours of CategoryI activityfar end-of.life cam everyfiveyears.These requirements, which became effectiveAugust 17,2011, are for physicianswho provide primarycare to patients (e.g.,emergencyphysicians,fanny physicians, general practicephysicians,Internists,neurologists,pain medicinespecialists,psychiatrists.)Exemption to the continuingeducation requirements for physicianson Mi-time duty in US Armed Forces, Reservesor National Guard (effective8/28/ 13).No formal recognition of OCC/MOC. however,physicianswho certifiesor re-certifieswith an ABMS or AQA specialtyboard tinting the licenserenewalperiod may claIm50 Category I credit hours. MalpracticeInsurance: Not requied

KANSAS Eduadosl Reqiiiremr-nis:Graduation from approved collegeof osteopathic medicine, Poatadute Tnininr 1 yearAOA or Board approved - &th 5 MDaJ1 DPM, 3 DOs, 3 public members, 3 DCs Board Address; Kansas StateBoard of flealingAns, Kathleen Sebler Jippetr,jD, Executive Director, 800 SwJacbon, Lower Level-Suite A, Topeka, KS 156612Phone U8 296-7413 Fax 083) 296-0352 Osteopathk Members: Ronaldit Vamer, DO Website:raw.ksbhaorg - . - Sunset Liw No ExaminadnnsAcrtoted: COML, NBO?.ffl, USMLE,FLEX or state examinationtakenprior to FLEX $300 FederationCredesiSisVerificationSeMceJFCVS: Willaccept for pitfessional schooLtranscripts,diploma,residency,and score zport Reciprocityor Endorsement:SPEC may be required SpecialLicenses:TFmporaqpostgraduateperutit-$50; temporary hill-practice - $50 - Renewal:Annual,.expircsJune30, Active - $330;Exempt or Inactive - $150 CME Requirements:50 hours per 1yearperiod, 100 hours per 2 yeasperiod, 150hours per 3 yearperiod:OCC/MDC not accepted as substitute. . - MalpracticeInstfrance;State requiresphysiciah to carry$200,000per occurrence, $00,000 per annualaggregate.

KENtUCKY EducationalRequirementsGraduationfrom anAOA approved college Pcatgnduare Thinin 2 yen AOA orACOME approved postgraduate training basi 10MOs, 2 DOs, 3 public members Board Address:KentuckyBoard of Medicallicensure, MichaelS.Rodmen, ExecutiveDirector, 310Whlnington Parkway,Suite lB. Louisville,KY40222 Phone (502)429-7150Fax (50 429-7158

ID OsteopathicMembec Dana Shifter DO, RandelGibson, DO Websitt kbmLky.gov Sunsetlaw: No Examinations;CO?vWEX,NBOME, USMLE,FLEX license Fee:$300; Graduates of Kentuckyme&ol schoolsto rnwa in Kenwcky forpostgraduate training-$175 FederationCrdendsls VedricadgoSrnicr (FCVS: Required Redproclrvor Endorsement, None Spedal ticn: Ternporaiypeonib to thosc th an unlimitedlicense hi another state, $75QicennircIce required i0 full —mustbe pnd online);an Institutional PracticeThmiicdlicense(II’)ors ResidencyTraining (K)licenseis reqtired of all traineesin order so enter their second yearof postgraduatetraining,$75 Renewal:Annual, byMarch 31;Actie - $150(online),$160 (paper);Inactive - 5250 ffleqnirrmcnn: 60 hours over 3 yean; 30 hours nrist be AMA otAOA Category1;and Clhours must be AIDS/V everylOycar period.)No specificmention of 0CC/MaC, however,a passingéat5cedon or recertificationexaminationof one of the specialtyboards that art members of the AmericanBoard of MedicalSpecialtiesor the AOA Bureau of OsteopathicSpecialistsaunts for 60 credit hours. MalpracticeInsurance: Currentlyavailableto physiciansin rhostate.

LOUISYANk

EducationalRequiraments:Graduation from a recognized osteopathic college - Post.rsduareTrai&nr I yen. Those servingas interns/residents in Louisiana must registerwith StareBoard of Medical Examiners.

Board Address:La AsiansStateBoard of MedicalExaminen,-Vmcat A. Ctilona,Jr, MD, ExecutiveDirector, 630 Camp Sc New Orleans, IS 70130Phone (304)568-6820Fax (504)568-5754 Osteopathic t4ember None Website:wwwjsbme.b&s6nn.pn Sunset bvt No ExaminationsAccepsn4:USLsUE,FLEJ COlvil..EXand NBOME Other Requirements:Fingerprints - $40.75;allphysiciansreneing their licensefor the FIRST time must attend a Board sponsored seminarpdor to renewal.The orientationis available4 times a yelr and acquaintsnewlicenseeswith the louisiana medical PracticeAc; function of the Board and it rules,.etc.Thytidana residingqnd practicingin another state at the timeofinidal rçnewal are exempt. l.icene Fee;$382 FederationCredentialsVetificationService(FCV: Required SpecialLicenses:PostgraduateYear I Registration- $50. Reciprocityor Endorsement: Interview and/or SPEX may be required. Renewal:Annual on or before the last dayof the month in which the licenseewas both - $332 C.ffl RequIrements:20 hours of AOA or AMA CategoryI per year.0CC/Mac not spcdflcaflyaddressed,but physicianswhohave been certifiedor recertifiedwithin the Inst yearby a member board of the American Board of Medics!Specialtiesor specialtyboard recognizedby theAOA are exempt horn CME rcquiraiicnts. MalpracticeInsurance;Most hospitalshave establishedminimum malpractice coveragerequirementsfor staff physicians. fl4E Edntndon,I Requirements:DO degree receivedkilowing a total of 36 months of pmftssional study. Postanduate Training: I yenc,AOA oiACGME approved £QUi6DOs,1PA,3publicmeznben BoardA1inirns:MaineBoard of OsteopathicIieensure, Susan a Strout, ExecutiveSecretary,142StateHouse Station, Augusta,ME 04333-0142Phone (207)2672480 Fax (207)536-5811 OsteopathicManbas:JoLi Brewer, DOJarncs Pisini DO; SconThornas, 00; BdanJ. GUlls,DO;Jchn F. Gaddis D0 RyanSmith, DO. Wth3it: wsvw.riwinv.govlosteo/ Sunset taw: Yes Fxaminrions Accented: C0MLE3 NBOME, US?aC..E,FLEX th&4i±zucnn: OPP is required if USMLEor FLEX was taken. . . - L!ctrnEct:$350 Federation CredentialsVerificationService(FCVS):Willaccept BGiprodtv or Endorsement: On indisidual basis-no reciprocity SpsciaLLbmsrTemporaryregistration for interns and residents - $200; Locum Tenens - $200;camp physicians- $200;visitinginstrectoc - $150. RenewaFBienniaLAn originalbsue &ense goes from the date of the issue until their next birth date depmding on whether the licenseeis born in an even or odd ynr. Renewalsarethen everytwoyears from Issuance - $525. CMEReo:.aircmIta: 100 hours of Board approved CME per2 yearperiod; 40 hours must be AOA Carory IA for F?, FM, OP and £vL All specialistsmay obtain 40houn of CaxgoryI CME hi their specialty. MalpracticeInsurance: Not required

II MARYLAND EducationalRequirements:Graduation from an LCME accredited collegeor any other medicalschool and have successfullycompleted the requirements for and obtained ECFMG certification. Po1gnduate Traininw ForANGs, 1 yearof postgraduate trainingin a program accredited byAOA, ACGME or the RoyalCollegeof Physiciansand Surgeons of Canada. FMGs require 2 years of training. fljxij 12iCs, 3 DOs, 1 PhysicianAssistant,6 public members Board Address:MarylandBoard of Physicians,ChristineS. Fancily,ExecutiveDirector,P0 Box 2571,Baltimore,MO 21215Phone (410) 7644777cr 00) 492-6836Fax (410)358-2252 OsteonathicMember Demean Freas,DO; Ann MarieStephenson, DO Websitt www.mbnsiate.mius Sunset taw Yes EaaminationsAccsad: USZ’.flE,NEME, NEOME, FLEX weightedaverage,FLEX components I and 2, MCC, and a passing score on allpirts of the examinationof anystate board or the District of Colusibia Board of Medicinein the United States. Liccnse9ee: Graduates of jtedicsl achoolsin the U. S..its territories,Puerto Rico,and Canada -$790; graduatesof foreign medical schools -$890 (includesforeign credaidais evaluation-$100). FederationCredentialsVerificationService(FCVffl:Willaccept ReciprocityorEndonement: Yes, reciprocity SpecialTicenses;Limited licensefor postwaduate teaching for I yearonly for purpose of post graduate teaching;Conceded Eminence. Renev?,l:Marylandlicensureoperateson a 24-monthcycle.A physicianwhoselastname beginswith the lettersA-Lmust renew his/ha licensebySeptember30, in even-numberedyears;a physicianwhoselast name beginswith M-Z must renewhis/her licenseby September 30,in odd-numberedyears,Physicianbienniallicenserenewal- 1512 (subject to change) CME Requiraments;A physician pplying for renewalshallearn at least 50 credit hours of CategoryI CME during the 2 year period immediatelypreceding the expirationof the physician’slicense.A physician applyingfor reinstatement shallearn at least 50 credit hours of CategoryI CME during the 2 yearperiod immediatelyprededing the submission of the reinstatementapplication.OCCThIOC not specificallymentioned, but the rulesrecognizeparticipationin a program of self-instructionto prepare for an approved specialtyboard certificationor recertificationexaminationunder the ABMSwhich occurs soldy’withina 2 yearperiod, on the hash of S hours of study equals 1hour of CME Category I creditup to a maxinum of 10 credit hours. MalpracticeInsurance: Physicianslicensedin Marylandmay obtain coverage from commercialinsurance.Anyphysician practicing medicinein Marylandmust provide written notificationto a patient if the physiciandoes nor maintainmediclprofessional liability

insurance coverage(msumncc)or if the insurancehas lapsed for anyperiod of time and has not been renewed. -

MASSACHUSETtS EducdonalSequiremenN: 4 yearsof not less than 32 weeks each in a kgnlly charteredmedicalshooL PostgraduateTraioinai 2 yearsAQA or ACGME approved program or accredited Canadianpmgram for US and Canadiap graduates;3 years forinternationalmedicalgraduates Q3g: 5 trOs, 2 publicmembers - Board Address:MassachusettsBoard of Registrationin Medicine, George Zachos,JD, ExecutiveDirector, 200 Harvard MillSquaw,Suite 330, Wakefield,MA 01880Phone (781)876-8200or (80 377-0550 Fax (781)876-8384 OsteopathicMember None Websire:www,ma,snv frngsrmedbnard

SunsetbwNo - . - ExaminationsAccepted:COMLEX, NBOME, USMLE,FLEX Other Reqialtanents:Criminalbackgroundchecks license Fec $600 FederationCredentialsV&fication Sen*e FCVSI:The Board accepts the,FCVS fcrveriflcatinn of core credentialswhich includes medicalschool(for pdmiiy source),postgraduatetraining,examinationscores and ECFMG verification Reciprocityor Endorsement: No SpecialTirenses:Limitedregistrationfor fellows,interns, and medical officers - $100.Temporary registrationto a physician: 1) holdinga facuityappointment at a reachinghospital(issuedCotno more than 12 months at a time and mayhe renewedtwice);2) substituting for a registeredphysician(no more than 3 months); and 3) enrollingin CtrE credits reqisitinglicensute (to terminateat the end of the CAB program or after 3 months, whichever comes tint) - $250. Renewal:Biennialbçginningon the date that the licenseis issued - $600 CMR/CPD Recuirementa:BeginningonJanuary 1,2018, whenever a licensee’snewtlicenserenewalis due, a newlycreated Ct’.ffiPilot Probjamwilj be effect for ONE bienniallicensingperiod.During this time, the Boardof RbgisrracioninMedicinewillgather feedbackwith the goal of making some permanent regulatoryamendments.The CAB Pilot Programrequires 50 creditsof CME during the biennial licensingperiod, to include2 CME creditsin End-of-Life Care issues as a one-timerequirement3 CAll creditsin oploid education and pain ànagementil the physicianprescribescontrolledsubstances;10CMBcreditsinRiskManagement,Mth maybe Category I or 2; 2 CME creditsfor studyingeaa6chapter of the Board’sregulations,243 CMR 1.00—3.00and these creditsmay be applied to the Risk Management equhemenq 3 CrABcreditsin electronichealth records as required underMGI. c. 112, 2, a one-timerequirement the child abuseand neglecttrainingrequired under M.GL c. 51A(k),a one-time requirement;the domesticviolenceand sexualviolence trainingrequiredunder MGI. c 112.5264,a one-time requiremeht Note: if a liccnscchas alreadysadafieda one-time-onlyrequirement prior tojanuary 1,2018, there is no need to retake the requirement, During the PiotPmgnm, biennialCME credits required may beh

12 alternativelearningftrnnatssuchas qualityassurance,selfor practiceaudits,HEDIS® reports,meetingMAClU measures,ctt In addition, licenseesmayclaim 1.00credit for everyhour of readinga journal or a point of care(FOG) resource accessedin the process ‘ofdelivecing patient care,or updatingclinicalknowledge.The Pilot Program applies to all active licenseeswho have a OdE requirement. It does nor apply to inactive or limitedlicensees.Fulllicenseesservingactivemilitaryduty in a unikm,ed service or the National t3uard thdng a nadbnal emergencyor crisisma’ be eligiblefor an txempdon from the CME requirement. All physicianswho serve adultpopulations must complcte a one-time CME course on the diagnosis,treatment and care ofpatientswith cognitiveimpairmentsincludingMaheimer’sdiseaseand dementia by November 6,2022. The Bond of Medicinei5narrentlyworking in develop the count, and pppllcantswho apply for a licensebetween November 7, 2018and Mirth 1.2019 arc granted an administrative waiverof thisrequirementfor thislicensingcycle. Malpndre Insurance: Stalerequiresphysicianto carry$100,000per occurrence,$300,000per annualaggregate. SpecialNote: As acondition of grantingor renewinga license,any physicianwho agrees to treat Medicarepatients cannot charge morn than the Medicareallowedamountfor that treatment.

MICHIGAN F.dsicatipij.&iamntl: 4ycars inAOA approved osteopathic college PostgraduateTninine I post-graduateyearof residencyin a programaccreditedby the ADA orACGIvIE. 1lard 7 DOs, 3 public members, 1 PA Board Address:MichiganBoard of Osteopathic Medicineand Surgery,CherylW. Pnon,JD, ExecutiveDirector, 611 Wi Ottawa 5t 1” Floor, Lansing,All 48933Phone (517)335-1001Fac (517)373-2179 Ostecp*thlc Member.: Dune L Parrett DO; WalkerFoland, DO; Stephen Bell,DO; Kathleen Kudny, DO;Jencilfer CozyBelier, DO: CraigS.Glints, DO;Jase Guasco, DO; StaceyDdz DO Wcbire www.rnichigangov/hesichlicenc

SunsetLawNo . - Eramitwions Accepted:COMLEXor NBOME forittitial licehsurcwillbe accepted for endorsement so longasapplicantha passed an examinationthat tested the applicant on subjectssubstantiallyequivalent to suects tcstcdin Midsiganinthe sameyear.

LicenseFee:$15 - Federation CredentialsVerificationService(FCVSbV’Waccept Recipnciw or Endorsement By endorsementwithall states with substantiallyequivalentcriteria Speciallicenses: limited Licraise,Interns andRcsidents - $216.80with ControlledSubstmceflrensq Controlled SubstanceLicense- 588.40; MilitarySpouseThnponq Ucensq SpecialVolunteer License Renewal:Everythreeyeats from issuance,December31 - $296.40,Controlled Stabtance- $244.10 C?,ffiRequiremcntsr150 hours over 3 years-60 hours must be earned through Category1 CME, with a minimum of 40 bonn earned in Categoryl.A maximumof 90 hours maybe earned in Category2..OCC/MOC not recognizedas substitute.Effective December 2017, requirement of Fain& Symptomrtanagement-Minimum 3 hours per 3-yearpedod (ISRA R33&243) - applies to all osteopathic physicians,includingresidents,whether or not they are inactive practice (a. retired, administrative,academicte,d’ing, etc.).Also, one time requirement,Trainingon Human Thfflcking (LAEA K338.123) Malpncticeinanunae: Not required

MINNESOTA Educational Recuirements:Degree from osteopathic collegerecognized by the Board - gTgjjjn: I yearin graduateclinicalmedical trainingin a program accreditedby the AOA or ACGME, or other graduate trainingapproved bythe Board. &&1MD,1 DO,Spablkmembers Bond Addees: MinnesotaBthrd of MedicalPractice, Ruth M. Martinez,MA,Executh’eDirector, 2829UniversityAve SE, Suite500, Minneapolis,MN 55414-3246Phone (612)617-2130Fax (611) 617-2166 Osteopathic Member None

Websire:www.bnn,.st.te.rnrtua . . SunsetIav Yes Enmlnations Accepted:COMLEZ NBO?¼ffi,USMLE,FLEX U’tICC - - Other Requirements:Interviewat Ucensure Committeediscretion. LicenseFee:applicationftc - $200:annualregistrationfee - U9Zcriminalbackgroundcheck $32 Federation CredentialsVdflc,i1on Service(FGLS: Acceptedbut not required - Reciprocityor Endorsement:With similir boards in stateswherelicenseIssuedby examinationwith gradenot less than 75 - STEXwiUbe required if physicianis not cuntady boardcertifiedandhas not taken a licensingexaminationwithinthe last 19yqars. SpecialLicenses:MedicalFacultyPhysician,limitedlicenseoption; and issuingUcesisesas a member board throught the IMLC Residency pennies kr physiciansin postgraduateclinicaltrainingprograms, $20.Tcbncdicine registrationis availableto physiciansproviding telemedleineservicesfromanotherstate. Renewal:Annual,month of birth - $192 CMERequkemenn: 75 hours per3 yearperiod - must be AOA or AMACategory1;OCC/MOC acceptedhi lieuof OdE requirements. Malpracticelnsunnce Not required -

13 MISSISSIPPI Educational Regoirranents:Diploma frtsi a collegeapproved by bOA Posrandtnre Tr&nint I yarAOA orACOME 8 MDs, I DOs,) PublicMembers Board kddrrst: MississippiState Board of MedicalLicemure, Kenneth B. Cleveland1.0, Executive Director, 1867CraneRidgeDrive, Suite200-B.Jackson, MS39216Phone (601)987-3079Fax (601)9874159 fl;teopathic Membec KirkKinard, DO Wabalte: wwwmsbmlsns.pov

Sunset L*wtNo - Examinations.Accepted:COMLEX,NBOME (ta]tenafter Feb. 13,1973),US1.UE FLEX Other R9ulrements: Backgroundcheck LicenseFee: $550 (online) Federation CredentialsVerificaton Service(FCV): Wi! accept Redpmdev or Endorsement:All stateswith equalrequirements. SPEX maybe required - exam given by the FSMB. Snedal licenses: Temporarylicensesissued under extreme conditions byexamination?reciprocity. Rencw4:Annua],June 30 -$200 CME Requirements:40hours every2 years of AOA Category IA or AM-ACategory1. OCC/MOC not recognized as substitute.If physicianpossesses a cuerentDEA certificate,5 hours must be in prescribingof controlled substances Malpncticc lncunnce: None

MISSOURI Educational Requirements:Graduation from an AOA approved college PostEradnareTrainine 1yearfor graduatesof AOA approved schools 6 MDs, 1DOs, I publicmember (Currentlyhave 3 tvDs and 2 DOs - can have up to 9 members.) Board Address: MissuuñBoard of Registrationfor theileafing Arts, ConnieClarkston,ExecutiveDirector, 3605MissouriBlvd.,Jeffenon City, MO 65102Phone (573)751-0098Fx (573)751-3166 Osteopathic members:JamesA. DiRenna,DO; David Tannebill,DO jw: r&mp.govJheaiio.nwp Smialaw: No Examinations Acccptcd:COMIS NEOMEJ USMLE,Hfl Other Requirements:Medicaljudsprndcnce examination license Fee: $75 Federation CredentialsVdficqdon Service(PCVSbWillaccept Reciprocityor Endorsement:9th states grantingequal practice tights,at the Board’sdiscretion. SpecialLicenses:Temporarypermits for interns, residents, fellows - $30 lZrawwl:Annu4 January31 - $100 All physicianswith Missouri licensesmust renew byjanuary 31 of each year. CME Requkements 50 horns bienniallyin ADA Category IA and/or 2A,AMACategoryl,or Amcdcan Academyof FamilyPractice PreacribedCredits. OCC/MOC not specificallyaddreisad, but a licenseewho obtained AmericanSpccinltyBond certificationor recertificationduringthereportingperiod shallbe deemed to have obtained therequired hours of CME. MalpracticeInsurance: A physiciana surgeon on the medicalstaff of anyhospitalIn a county that has a population of more than 75,000 people must (asa conditionto his/ha admission tool retention on the hospitalmedicalstaff) havea medicalma practiceinsurancepolicy of at lent $500,000.Theserequirementsdo not apply to physiciansor surgeonswho limit their practiceexclusivelyto patientsseen or treated at the hospital and areinsured enlusively under the hospital’sinsurancepolicyor the hospital’sself-insuranceprogram.

MONTANA F4ucscional Requirements:Graduation from a school accredited by theAOA, LCME WHO Posgnthuatc2’raining Completionof a residency.Graduates ofmedicalschool p&2000 who did not complete residencycanmeet requirement with trainingand experiencethe Board determines is equivalentof an approved residencyprogna 3yean residencyrequired for fl{Gs. I DO, 5 ?vIDs,1DPM, I PA-C, I RID,2 PublicMembers, I VolunteerBC?, I LAc Board Address: MontanaBoard of Medics]Examiners,Ian Marguand,ExecutiveDirector, P0 Box 200513,Helena,MT 59620-0513Phone (406) 841.2360 Fax (406)841-2305 Osteojnthic MeniberMollyBleN, DO

Website: www.medicalhoard.mt.g . - - Sunset Lw No, althoughLegislatureCLI order reviewof boards. Last reviewin 2011. Examiniajons Accepted: CONUfl NBME, NBOltE, USMLE,FLEX, LMCC,ECFMG License Fee:New applicationfee - $500;initiallicensesit Interstate Cqsnp.cc:$500 Fcdendon CredentialsVedfi:idnn Service(FCV; Wallaccept ReciprodtvotEndonemenr: No reciprocity.Statute repeded in 2015. SpecialLicesasnsResidentlicense--Iye, renewableas long as licenseeremainsin program. @SCA37-3-301)Temporary andTelemedkine licenses repealed2015-The Board can grant short-tam non-disciplinarylicensesat its discretion. QvlCA37-3-305) Rncwal: Biennialfrom theyearof issuance,onlinerenewalsFeb 1 - March31 - 5SOOActhe;$400Inaaivq $6flMontanaPrescription

14 Drug Registryfee assessedat renewalfor prescribers. CMKRuirements None Maipndce Inaunoca: Not requited

NEBRASKA Educatonl Requirements:Graduation aftekjanuary 1, 1963,approvedby the American Osteopathic Msodadon Bnrcau of Professional Education, or prior mJanuary 1963upon Board approval. PostgraduateTraininr 1 yeasat an 404 orACGME approved program. PQard:5 MDs, 1 DO, 2 publicmembers Board Address: NebraskaBoard of Medicineand Surgery,Jesse Cushinan,Program Manager,301 Centennial MallSouth, lincoln, NE 68509Phone (402)471-2118 Fax (402)472-8355 Ostuqnthic Membenjodanne W Hethick, DO Website; http://dh&.ne.gov/Pnaes/default.aspx Sunset Uw No ExaminationsAccepted:COMLEX,NEOME, USMLE,FLEX Jicense Fcc:$300 Federation Credenthis Verificationservice (FCVS):Complete profilesmaybe submitted. The profile willbe reviewed to determineif its components meet the docu,ncntationreqokeme,its for Ucensure.A profile is not automatic acceptance of the documentation veil Cedby FCvS. Reciprocityor Endorscmcnr:For applicantswho took a sate board, upon Board approval Syccialticenses: None Renewal:Biennial,even numberedyears,October 1 - $121 50 hours Catory I every2 years,approved by404 or ACCME. OCCJMOC not recognizedas substitute. Malnncflcc Tnsunnce: Not required, but requires mandatory reporting of czncefleapmfessional liabilityinsurance,or the decisionnot to Carryprofessionalliabilityinsurance.

NEVADA Educational Requirements:DO degree &omcollege requiring actualattendanceof 36 months, and offeringcoursesspecifiedIn the statute, Postgndtnte Trauun .Pdor tojanuary 1, 1995:1 year internship; afrerJanuaq 1 1995:3 years of ACGME or 404 postgraduate training. A DO who is enrolledin apostgraduate training program in Nevadacan teethe an unlimitedlicenseto practicemedicineafter completion of 24 months of the programin thisstareand has committed,Inwilting,that he/she willcomplete the prognian azd& 5 DOs, 2 publicmembers Bond Address:NevadaStateBoardof OsteopathicMedicine,SandyL Reed,f.fl’A,ExecutiveDirector,2275 Corporate Circle,Suite210, Henderson, NV 89074Phone (702)732-2147 Fax (702)732-2079 Osteopathic Members:RonaldHedger, DO; SamirPancholi, DO; 1¼uItrhusling,DO Richard Alzr.agucr,DO; C.Dean Mike, DO Websitt www,bom.nv.gov SmisetLaw:No ExaminationsAccepted;COMLEX,NBOME, USMLE,FLEX, SPEll OtherR9uirements: Criminalbackgroundcheck (fingerprints)and interview Ucense FeetapplicationandInitialfee- $670 (DO), $470 (PA) Fedenjion CredentialsVedficationService (FCVS’nRequired — DOs only,not PM Reciprocityor Endorsement:No rcdprodty we have license by endorsement. Speciallicenses: For residents Hcn1: Anoual,Januaq I.- $450(DC)),$250 (PA),$200 (Residents);Inactive- $200 DtlE Requirements:35 hours404, AMA orACCME per yearwithat least 10hours completed in CategoryIA coursesand two (2)hours that relateto the misuseandabuse of controlled substances,the prescribingof oploids or addiction. Aerjuly 1,2018, within two’(2)years after initiallicensureand at least once everyfour (4)years thereafter,must talteinstruction on evidence-basedsuicidepreventionand awareness. MalpracticeInsurance:Physicianslicensedand activelypracticingin Nevada must ca professionalliabilityinsurancein an amountof $1,000,000per pason/$3,000,000 per occurrence (not requiredbylaw).

NEW HAMPSHIRE Educational Requirements:DO degreefrom an404 approved college Poatgraduate Tnhuinr 2 yearsof formal postgraduate training at an institutionaccreditedby the ACGME, the 404 or in equivalent Board:S MDs, 1 DO, 1 PA,3 Public Members,the Commissioneror the MedicalDirector of the Department of Health and Human Services,or in the case of a vacancyin the Office of MedicalDirector, the Commissionershallappoint a designee Board Address:New HampshireBoard of Medicine,Penny Taylor,BoardAdministrator,PhilbrookBuilding,121S. Fruit Street,Suite 301, Concord, NH 03301-2412Phone (603)271-1203Fax (603)271-6702 Ostmathlc Member.Jnhn H. Wheeler,DO Website https//www.nnk.nh.ov/medkmne/ Sunset Law No Fnminasions AcceotethNBME,NBO, USMIE, FLEX, LMCC. Ii &dention RenewaL not license collect Malprictir.e Reciprocity require. Scedal certification C?s{E Websirt board Enruinations Phone Sunset Postgraduate NEW Board Osteopathic milltry Educational &zinafiomAccta4: $1,000,000/occurrence CMR Sunset July!, Malpractice Federation License the Special Reciprocity pEtid Renewal: Website: OCC/MOC flo-nd Osteopathic Hoar, at ABMS required NEWJERSEY Postasduate Educational nmiagemenr preceding same Malpncdct Board, proof Reciprocity &twirCredenSh jjcseFee:$300 Special CMR Renewil specifically medical Retirements: field Requirements: during Address: Rcquirements of Trenton, mniaiauraof MEXICO Aildtrss, Law (505) 2003:2 3 Ucenses I.aw Licenses; 11 or shall Fec physicians Licenses: $200,000 Fee; wtuw.rld.stesirn.m)bcards/Oveopathy.aspx DOs, Annual, wuswsrsten[us/lpa/caJbmelthdc.hnnl for being Biennial Biennial, AOA). MTh, 2years. or Credentials Credentials or Insurance: boast) by or 1ncunncePhysidans No Rcquhcnenrsr or Membm: $400 Insuronna: 4764629 Requirements: No be Members: not lieesisurt $610 the Tninhi and would, Trainioz Accepted: Endorsement: Fodorsement years addressed, a 2 Endors&ncrn: up considered New NJ Newjescy specialty Temporary public ZOOs, three accepted None on LocumTenets-$150 policy addiction a odd Ucemcs to and n-en 08608 letter $200,000 75 of or when 100 Mexico Proof date yeas Fax State Vedc,tion yean,June I William temporary Vei1ficationService AOA Slate Otto Vedrication members and before hoots Graduated mat years COMUIY( year I CO14LEC, hours board of however, on as Phone OEM, (505) tonsidatti to cycle. Graduate $3,000,000/year, 4 disorder at law State permits credit substitute. Sabando law must All Board a least or AOA Applicants years from oIAOA have Eniewed for July every program Brkman, of requires ACGME during 476-4665 states requires Included Board I (609) licenses out arerequired 30’s CME $600,000 complete from Service physician, in completed lab 1 from physicians orACGME - of Service biennial granted NBOME, or NEOME, of of bond DO; $200 together, - having Oiteopathic director, orAMA S26-7100 the a $580 an on of of credits the a state must method cbmbination, a DO;)ernny approved issued screening in (FCVS: maintenance 3 AOA John Medical consortium an (FCVS: (FCVS): in tourer, 3 approved license mitil year and the if $600,000 physicians. requirements hours ciii their individual start cash to - US1flE, paid during US?.aE, Category be I acciethted D’Angdo, on 75 sthool approved also showpmof government cycle Fai next satisfy credited continuing Medicine, on at Examiners, Will renewal ptgmduaft Will hours cnn and panel during of Required to beginning - (609) Edmond,, osteopathic each meeting file as or onlinc of total pdor of accept, carey the FLEX 2czepr basis CME FLEX, years 1 a Passage companies to are if certification internship per medical ctndition I” equal DO; toward 826-7117 biennial bwiitipma in that provider review of Roberta toJuly continuing 6 tall rnaetht, ycar liability medical and 3 requirements of William hours hIily carrying of Joseph individual the yen Dojames training to end of the coh]est application oh the - odd schl all license or liccnstc the 1,2003: to for program. wants period &nd coverage olpoin recommends action. Perea, liability greater criteria education biennial by V. years provide I A. SPEC medical penalties license education PA, and of the Rncder, state Bacaqelti, rcnewtl protection or by has Baum, Boast) osteopathic osteopathic for 1 management Patient has 1 physician’i than for process. suit, yearAOA of acdv With compledpg CNM, renewal licensing malpractice renewal, completed liability licens!s cequirerneat signed $500,000. certification for 3D, New or and Administrator, cycle, DO;John a Compensation DO membership those score pns 3 of Executive Interview report period: public insurance. a Meco, issued physician 0CC/Mac medicine examInations specIalty other with orACGME-approvcd contract or an certification 100 of who insurance Ucensare - 2 for online by Cniickshanlç 75, 40 to members, provisions hours $290 hours on don’t cennl Need the a Director, may of during organization, -- in assistants RO. and Thcyarerequimd single odd for Fund which examination, in AOA preceding peryear. accepted, to of applicants be a - surgery taken Certain to years, 2’yar or Box disciplining 3 physicians approved the specialty required. State meet pays of re-certification being or 140 year DO 25101, 3 piorto the June30- certification year exemptions the Commissioner all East 2 ala as deemed Medical (2 program are category years. stare in bond licensees difference. CME ycaØ cycle. in Santa board. required bienniji Front the December to the requirements. $350 carry adequate area must recognized Malpractice within OCC/MOC by Fe, I ratt or gndtnted Suecc are Patients who credits. - renewal a it l’Jlf to of Statute of be specialty made It provide pain the 31, show Health in 3d is by R7505 can the not 1972 by for after te Act. 16 NEW YOEX Educational Requiremenet Pta-professional education consists of satisfactorycompletion of 60 semester hqurs of collegestudy hom.a NwYork Stare registeredprogram or the equivalent as detcmilncd by the NYSED. Evidence of professional education may bt (1) sads&ctorycompletion of a medical program registered by the NYSED as liecnsure-quaU’ing or accreditedby the AOA or the LCME and have receivedthe degree of MD, DO, or the equivalent,if graduatingfrom a reglsteiedor accreditedmedical program, or (2) satisfactory completionof no less than32 months inn medical program recognizedas an acceptableeducationalprogram for physicians by the appropriate civilauthoritiesof the country In which the school is located and have received the degreeof MD, DO or the equivalent as detetinlntd by the licensuredepartment and a satisfactoryproficiency’examination,such as the Educational Cospnission for Foreign Graduates @CFMG) ceitifldation,if graduating froma non-accreditedmedicalprogram. PostgraduateTraining:If paduadng froma registeredor accreditedmedicalprogram, atle2st 1yearof postgraduate hospital trainingin an accreditedresidencyprogramapproved by the ACGME, the AOA, or the RCPSC;it graduating from a non-accredited medial program, at least 3years of postgraduate hospital trainingin an accreditedresidencyprogram approved by the 3 orgazilnflóns listed above Dnas± 2 DOs, 17MOs, 2 Ms, 2 public members Board Address:New York Sate Board for Medicine,Stephenj. Boese,ExecutiveSecretary,89 WashingtonAvenue12t Door,West Wing, Albany,NY 12234Phone (518)474-3817ext 560 Fax (518)4864.846 Osteopathk Member,: licensing Board: Lynn C. Mark,DO; AmirM. Shela; DO Website: hnp:/fwwwnp.nyced.gov/prol/med/ SunsetLaw: No ExaminationsAccepted:NBOME/COMIfl NBME,USMIS, FLEX license Fee:$735 (mdndes licensefccand first registration) Federation CredentialsVedficationSe?vice(FCVS: Required forgnduates of non LCtAE urAOA accreditedor board approved medial schools Reciprocityor Endorsement: Yes,at the discretion of the Board in •ted circumstances SpecialLicenses:LimitedPermits to practice under the supervisionof a New York State licensedand currentlyregisteredphysicianand only in a generalhospital, nursinghome, state operated psychiatric,developmentalor alcohol treatment center, or Incorporated, nonprofit instiwdon for the treatment of the chronically111- 5105;3 yearlimited license,and waiver of the citizenship/permanent residence rcquirement,in exchange for the physician’sservicein a medicallyutdemerved area of New York State. Renewal,Biennialstarting on the first day of the physician’sbirth month- $600 CME RecpiiremcntaFor pxcscdbas who have a DEs\ rcglstradon number to prescribe controlled substances,as wdllas medical residcnts who prescribe controlled substancesunder a facilityflEA registration number, 3 hours of course work or trainingin pain nnmganenc palliathe careand addictionmust be completed bctweenJuly 1, 2015antiJuly 1,2017, and once every3 years thereafter.The course work or trainingmay be live or online,and must include the following8 topics:New York State and federalrequirements for prescribing controlled substances,pain management,appwpdateprescribing, managingacutepain, palliativemedicine,prevention, screeningand signs of addiction,responses to abuseand addiction and end of life care.The topics can be completed in a singlepresentation orinindividual segmentsfor a total oEat lcast3 hours. Prescdbeis licensed on or afterjuty 1,2017. who have a DFA registration,nsweil as medical residentsprescribing controlled substancesunder a facilityDESkregistration,Shallcomplete the coursework or trainingwithin 1 yearof registration,and once withineach 3-yearperiod thereafter.A prescriberwho obtains a DEA number afterjuly 12017 must complete the

eourseworkwithin one yearof DESkregistration and once within each 3-yearperiod thacafter. This requirementalso appliesto a - prescriberwho is licensedin New york, and who has a DESkregistrationnumber (regardlessof the locationfor whichit was issued), who practicesin another state, or who is not currently practicingin New York Board certificationoireeerdflcatlon is not a substitute for the required coursework or tnining however, course work or trainingcompleted to obtain bothd certificationor re&rrificationmay be applicableto 1or more of the 8 required topic areas,and toward the minimum of 3 hours in duration.

MalpracticeInsurance:Not required -

NORTH CAROlINA EducationalRequirements:Except for graduates of foreignmedicalschools, applicantsmust have graduatedfrom a medicalschool accreditedby the Uaiso,i Committeeon Medical Education (LCM, the American Osteopathic Association(ADA)or the Committee r the Accreditationof CanadianMedicalSchools. PosrdunteTnining 1 year 1narth 8MDs; 1 who is eithera DO, a fall-time NC medicalschool facultymember who utilizesIntegrativemedicinein that person’s clinicalpractice,or a member of The Old North StateMedicalSociety;3 public members; 1 PA and 1nurse practitioner Board Address:North CarolinaMedicalBoard, it DavidHendcnon,JD, Chief Executive Office4 P0 Box20007,Raleigh,NC 27619 Pbone p19) 326-1100Fax 1! 326-1131 Ostenparhic Membec BarbaraE Walker,DO; Chthdñe Khandelwal,DO Websise: www.ncmedhoard.ow - Sunset Law:No. Examinations Aréeptrd: COW.EX NBOME, USMLE,FLEX, NBME, u4cç MCQUE, state boardwritten Other RequIrements:Physicianswho have been out of clinicalpracticefor 2 or maté pin may be requiredto developa “re-entry” plan as parr of dick application. - License Pee:$440 (includescriminalbackground record check ftc - $38) - Federation Crdenthh VerificationService(FCVShRequired fnrIMGs plus $2.00fee for NPDB report and anyonewith a completed FCVS profile

17 Rednrodry or Endornmeit: Must pass an cxaminationfor licensetcstin generalmedicalknowledge(examinationdetennined by the Board to be equivalentto the Board’senminadon). Originalcertificationof passing scores mint be provided ‘a the Board from the enan flat on source. Interview may be required.SPEC may be rtqiilred. Certificationor re-ceetificadonThoma specialty board recognized byABMS or 404 within the last 10 yearsmay exempt applicant from taking the SPElL Specl2llirenscs Resident’sTnining license -$138; Medical8th00l Facultylicense - $440;RetiredVolunteer - no fee; 3peciaiPurpose - $440;Ltd Volunteer — no Ice, All licensure feesinclude criminalbackground record check fee - 138plus $2.00 fee for NPDB report. Reneral: Anuu4 within30 days of birth date - $250 CME Requirements:All physicians,except those holding a midcnq traininglicense shall completeat least 60 hours of 404 a AMA Category 1 CME relevantto the physician’saiuon orintende spethityor area o(pncticc everythree yeast Beginning onjuly 1,2017, everyphysidnwho prescribes controlled substances,except those holding a residencytraininglicense,sinE complete at least three hours of CME, from the required 60 hours of CategoryI CME, that is designedspecificallyto addresscontrollcd substance prescribingpractices. The controUcdsubstance pracdbingC!tffi shallincludeinstruction on controUedsubstance prescribingpractices,recognizing signsof the abuse or misuseof controlled substances,and controlled substance prescribingfor chronic pain nnnaganent A physicianwho is continuouslyengagedin a program of recertifithion, or maintenance of certification,from an ABMS,404 or RCPSC specialtyboard shall be deemed to havesatisfiedhis or her entire OtiS requirement for that three year cycle.Any physicianwho qualifiesfor the aforementioned exemptionand who, as pm of their recertificationor ranintenanceof certificationprocess, completed CME that specificallysatisfiesthe controlled substance prescribingO.ffi requiremaitis not required to take controlled-substanceprescribing ci.rn beyond tint indoded in their MDC proces

• MalpracticeInsurance:Not required, but mandated repor ng to the Board of any damageaward or settlement 012 malpractice claimwithin

• 30 days of suchawardor settlement.

NORTH DAXOTh - F1uational Require.msau:Graduation from gn osieopatbie collegelocatedin the United States PostataduateTnining. I ycar in approved AMA,404 postgraduate trainingprogram or by an accredidngbody approved by the board. &ad9MDs,IDO,1PA,2publicmemben BoardAddrass; Narth Dakota Board of Medicine,Bonnie Stothakkcn,JD, Executive Secretary,4185. BroadwayAvenue, Suite 12, Bi,mäsck, ND 5S501Phone (701)328-6500Fax (701)32S-6505 Osteopathic Memhec Thomas D. Carver,DO Webaire:uiwwndborxjjarg Sunset Law:No Examinations Accepted:COMLEX NBOME, USMLE,FLE3 and state written exams UcenseEti $200plus criminal background check ke- $40 (rotalIce - Federation CredentialsVerificationService(FCVS: Willaccept Reciprocitya Endorsement: Non; Speciallicenses: Temporaaypermits pendingpossible interviewbclott the Board (onlyafter applicationprocess is complete). Locum Tenea’ permits fQrperiod not to exceed3 months. . Rcncw2l:Annual,Expiration dates are annuallyon the physiciansbirthday4205 (online);$250 (paper) CME Renuhements:60 hours of 404 orAMA Category I per 3 year reporting period. OCC/MOC not accepted as substitute. MalpracticeJncum4cs:Not required

OHIO Educational Requirements;Diploma fromADA approved osteopathic college PnstgnduatrTrning1 ynr,AOA orACGME-appioved !sxat±7 !Cs, I DO, I DPM, 3 public members BonrdAddress; State Medicall1ond of Ohio, AnthonyJ. Gmeber, 1’WA,Executive Director, 302. Broad Street, 3d Floor, Columbus, OH 43215-6127Phone (614)466-3934Fax (614)728-5946 Osteopathic Member Sheny Johnson, DO Website:wwmed.ohioauv

Sun,erlasrNo - &qmhntionc Accepted:COMLE NEOME, USMLE,FLEX Ucen’e’Fc:: $305 Federation CredentialsVeificatino Service(FCVM:Required Reciprocity orEndorsemcnr None Speciallicenses: InitialTraining Certificatesfor interns, residents, and fellow,in approved programs - $130 for three (3) years;one renewal permitted - $100;Spethi ActivityCertificate-$125; Cinical ResearchFacultyCertificate-$375;Triemedidne Ccti&ate - $305; Volunteer’sCcrtificate— no fee. -. Renewal:Each person holding a licenseissued snide this chapter to practicemedicine and surgery,osteopathic medidor and surgery,or podiatric medicineand surgerywishing to rein that licenseshallapplyto the bond for renewaLApplicationsthE be submitted to the board in a manner prescribed by the board. Path application shallbe accompaniedby a biennialrenewalfee of $305. Applicationsshallbe submitred according to the followingsched,ile 4* (a) Person, whoselast name begins with the leers through “B,”on or before the first day ofjdy of everyodd-numbe&d year; (b) Persons whose lastname begins with the letters “C” through “fl,’ on or before the first day of April of every odd-numbered year;

18 - (c)Personswhose last name beginswith the ietters “B”through“G,”on or before the first day ofjanuary of everyodd-numbered year; (ii) Persons whose last name beginswiththe letters UHIthrough ‘ic”on or before the first day of October of every even-numbered year; (e)Persons wbisc last name beginswith the lttem ‘1” through M,° onrar before the Lntdsy ofJuly of everycveä-numbead y&; Persons whose last name beginswith the letters “N” through MR,”on or before the first day of April of everyeveti-numbered year; CO S,’ (j Persons whose last name beginswith the letter on or before the first day ofJanuary of everyeveo-nu±beztd yen; Qi)Persons whose last name beginawith the letters ‘T’ through “Z,” on or before the first day of October of everyodd-numbered yen. The clinicalresearch FacultyCertificatelasdil renewedeverythree ynn CMEReqjirement,: 100 hours over 2 yeariedod; at least 40 hours must beAQA CategoryI with the reunhdsg 60 hours is CategoryI or 2. OCC/MOC not accepted as substitute. ClinicilResearchFaculty Certificate— 150hours over 3yearperiod. MriipncticcInsurance:Not required, but must providepatientswith a wnttcn noticeof du physidan’s lackof insurance coveragepriorm

providing the patient with nonemergalcy care, *

OKLAHOMA - Ed,,casic,,,alRccu,irenicntt Grathiaflon from an osteopathiccoL’ge chatis accreditedby the Bureauof ProfessionalEducation of the American Osteopathic Association. Pos*gradoateTnining Completion of a 1year AOA-appmvcd rotating internship or its equivalentthaeo in an accredited internship or residencyprogram acceptable to the Board. If an applicanthas completed an ACGME scar&ttd residencytni’dng program and become specialtybo,id eligibleor attained specialtyboard certification,the Board mayconsider this standing as equivalenttraining. m& 6 DOs, 2 public members Board Address: OklsimmaState Board of Osteopathic Examiners, George Robinson Stratton, III, Exeqdve Director, 4848 N lincoln Blvd, Suite 100,Oklahoma City,OK 73105-3321Phone (4D52B-6625 Fax (405)557-0653 Qirtrtathic Members: Cat]B. Petligrew,DO;Jny D. Cunningham,DO; Dennis). Carftr, DO; Bret L.engemian,DO; Duane Koebler, DO;LeroyYoung, DO Website: vr*w,okguv/osboe/ Sunset Law;Yes ExaminationsAcceoted: COMLEX,NBOME

license Fee: $575 - Federation CredentialsVerificationServiceffCVS):Wdladeept Redprothy or Eridrwsemenr:.Withsmtes havingequalrcqukanents, at the discretionof the Board - Interviewmaybe required. Speciallicenser: None Renewal:AnouaLJuly I - $225(in-state);$150 (out-of-state) CME Requirements:16 hours per year is AOA Category1A or B, 1 hour ci which cvny.other yearmust be in the area of proper prescribingof contxollc&dangcroussubstances.0CC/MOC not accepted substitute,however, the OklahomaStateBoard of Medical licensure and Supervisiondoes accept specialtybond certificationor recertificationthat was obtainedduring the three year reporting period, by an ABMS specialtybond. MalpracticeInsurance:Not required

OREGON EducationalRequirements:Graduation from anAOA approved college fndinre Trsininr 1 yearAOA or ACGME, as approved by Board lim& 7 MDs, 2 DOs, I DPI.!,2 public members = 13Board members Board Address:Oregon MedicalBoard, Nicole A. Kdshnaswami,JD, Executive Director, 1500 SW1stAvenue,Suite (120,Podand, OR 97201-5915Phone (971)673-2700Pa )7l) 673-2670 OsreopathinMembers: K Dean Gubler, DO; ChristorTa Poulsen,DO Website nvw.orespn.govJOMB SpncetLaw:No

EXamination, Accented: COMLEX,NEOME, USMLE,FLEX - Other Requirantt: Board is authorized to conduct nationwidecriminal jecords backgmurd check and fingerprintson 2pphcants and licensees. license FeeiApplication fee - $375;criminalbackgroundcheck - $48 (total fee - $423) FederationCredentialsV&fieation Service(FCV: Willaccept Reciprocityor pdanem No reciprocity.EXpeditedEndorsetent request reviewedon an individualbasis.Committee/Board review may be required prior to issuanceof licensuri SPElLmay be required. Soethl licenses: No longeroffered Renewal:Biennial.}556, must be receivedon or before December31 of each oM-rntmbered year. CME Requirements:60 hoqn of AOA orAiJA Cai±goryl everytwo years;nort 15hours of AOA orAMA CategoryI every two years for OCC/MOC conwlir.t applicants - MalpracticeInsurance: Not required.

PENNSYLVANIA Eduntiornl Reoukemetus: Graduation from board approved osteoputbiccollegemeetingsamtoq ateda PosrgnthisreTninin I ytarAOAspprnvedzotatinginternsffip -

19 aith 6DOs, 2 public members, I respiratorycasepractitioner or P4 or a certifiedathletic trainer, or a licensedpàfusionist, Commissionerof Professional& OccupationalAffairs, Department of Health Representative board Address:PennsylvaniaState Boardof OsteopathicMedicine,Aaron Malinger,Administrator,2601 N. 3’ Street, flandsbwg, PA l7llOYnone (717)783-4858Fax (717)787-7769 Qgçapathic Member,: Frank Tursi, DO Christopher Poj, DOi John Bulger,DO; Rind>’Lermn,DO; Burton Marie,DO; William Swallow,DO Web&te: www.dns.sbie.pa.us Sunset LawNo Ex*minatiornAccepted:CO?CE NEOME, FLEX Other Requlreinenr: Examinationin Olfl required for flccnsur; fee $250. Deadlinedate for application.60days prior to examination. EffectiveMarch 29,2006, DOs who hive passed COMLEX-USALad 2-FE, OwOsteopathic ClinicalSkillsExamination, arc now exempt from taking the state board’s OIfl’ examination.Effective March 12,2008 the En! addressedthe issueof whether noappièanr for liccnswewould be required to complete.the OMT examinationif applicant had alreadysuccessklly completed an osteopathic bead certification examination,that induded an OMT component or who alreadysuccessfullycompletedan OMT examination as a requironent for another state lie nse. The applicantswould be deemedto hive met the Beard’s OMT examinationrequirement if the applicant can provide proof to the bard that bc/she has completedan osteopathic certificationexaminationthat induded an OMT component or provide proof that the applicantcompletedan OMT ocam nation as a requirement fur another state license.TheBoard v.1!]reviewthese requestson a case-by-casebasis. - license Fee: $45;Applicantsrequiringthe state board’sOMT enminadon: first timeOlvfl’examinationfcc 4250 (rho exam is now administeredthrough PearsonVUE All examfeesare paid directly to PearsonVUE. Their website is http;//www.pearsonvue.comfpa/osteopathic-mcdicine/). Repeat ànmination fee $170 (additionalstate board’sOUT examination inforlnadon and applicationavailableon ProfessionalCredentialServices(testingagencyweb siteat www.ocshq.com)Applicants not required to complete the state board’sOMT examinationfee -$45 FederationCredentialsVedflcationService(FC’M: Yea Redprnchv or Endorsemeon By endorsementwith stateshating equal requirements,provided applicanthas not previously faileda Pennsylvaniawritten examination. All applicationsreviewedon an individualbasis. SpecialLicenses:Graduate tnining.cert5cate — is a renewable 1year temporary certificategranted to osteopathicphysicians licensedin the Commonwealthor another state ttAioappliesfoitraining or certificationin AOA approved Insthutlans that allowsthem to practice only within the complexof the hospitaland its afilates or the community hospital where the physicianisergaged in training. Tcmponq license — is a temporarylicensevalid furl yearthat is granted to osteopathic medicalcollegegraduatesfor permission to participate Law approved gndoatr ostaapathic or medicaltrainingprogram in the Commonwealth. and only pennits the licenseeto train only within the complexof the hospital and its affiliateswhere the licenseeis engaged in an approved trainingprogram.Short-tam camp physicianlicense — valid lola period not exceeding) months, maybe granted roan osteopathic physicianlicensedin goodstanding in another state or Canadawho intends to practice in • camp;must complywith malptacticeinsurance requirements. Renewal:Bknniai, before October31 of everyeven-numberedyear - $220 CME Reauiremen: Completion of 100credithours of continuing medical educationin the preceding2 yearperiod, which runs from November 1o1 the evenyear through October31 of the next even year.At least 20 of the 100 credithour, must be completed in AOA Category1-Aactitida At least 12 credithours shallbc completedin Category I or 2 approved activitiesin the an, of patient sskty/rtk management.At least two hour, of a Board approved childabuse recojnition and reporting continuingeducationwill be required.Acleast two hoursmust be completedin pain management,the identification of addiction,or the practices of prescribingor dispensing of opioids. The remainingcredit hours shallbe completedin any CategoryI or Category2 approved activities.OOCThIOC not accepted as substitute. Malprasticelnsnranu: Physiciansconductingmore than 50% of their practicein staremust careyinsurancewith Umlesof $500,000per occurrence/$l,500,000per annual sgcegate in compliancewiththe professional liabilityinsurancerequirementsunder 711 of the MedicalOre Availabilityand Reduction of Error (Mcare)Act No. 1 of 2002.

RHODE ISlAND EducationalRequirements:Graduation fromAOA accreditedosteopathic collegeS - PostgraduateTrnirilngiTwo yam in hospital or equivalentpostgraduate training approved byAOA or ACGME p 4 MDs;2 IDOs;5 Public members,one of whom is an attorney with apcdence as plaintiffs counsel a the presentation or prosecution of medicalmalpracticematters, and one of whom is a member of the generalpubli; not associatediviththe medicalfield, who is at least60 yearsof age; I hospitaladrninistsator director of RI Department of Health &ard Address:Rhode IslandBoard of MedicalUcensure and Discipline,James V. McDonald,MD, 2’OIl, ChiefAdministmtive Offlmr, Department ofHealth,) CapitolHill,Room 401,Providence3RI 02908-5097Phone (402)222-3855Fax (401)222-2158 OsteopathicMesnbezs:Siexlos Canyannopoulos. DO; CatherineDeGoo4 DO Website hrqrf/www.hetilrhsigov Sunset Isw No Enminations Accepted: COhCE( NBQME, USMLE,FLEX, LMCC Other Reovirements:OPP maybe requiredif USMLEor FLEX is presented for licemun interview. license Pen $1090,ControlledSubstanceRegistrationfec$200 Fdentk,n CredentialsVerificationService(FCVS: Required Reciprocityor Endorsement Pull applicationprocess SpecialUcenrectUnited licensesfor training,intern, resident, fellow-$65

20 Rnwal: Biennial,before the 1st ofjuly of mcli even-numberedyear, - $1090 CME Requirements:40 hours of CategoryI per 2 ycar.period,at least 4 hours of continuingmedicaleducation shaHbe earned on topicsof current concern as detemilned by the director of the Rhode Island Department of Health. Current topicsincludra ethics, risk managanenc opiold pain managanent/thronic pain management, end of Life/palliativerare and antimicrobialstewardship. Malpracticeinsurance: Requiresproof of liabilityInsurance,but dots not specifya particularamount.

SOUTH CAROLINA Esucafional Requirtnenta: Graduated &on a school of osteopathic medicine accreditedby the Commissionon Osteopathic College Accreditation(COCA). Poet dua1cYrairlng I year,as approved by the Board &ar± 7 physicIans[MD or DO] [representingeach of the 7 Sc CongressionalDistxictsj,2 at-largemembers [MDor DO]. I DO [permanentlydesignatedsent],3 Lay [public/non-phys1can3members Board Address, South CarolinaBoard of MedicalExaminers,Sheddon H- Spoon. Esq.,AdminIstrator,110CenterviewDdve, Suite202, Columbia,SC 29210 Phone 03) 896-4500Fax (803)8964515 Osteopathic Members:Ronaldjanuthowski, DO Website:vrww.Hr.state.sc.us/pol/mcdical Sunset lsw No Examinationthcccpted: COlilfl, NBOME, US?vfl,E,FLEX Urenee Fe, $580 FaeMm, Credentials-VerificationService(FCVSI:Required Rtdpmdty or Endorsement lnteawewrequired - SPEX or COMVEX may be required. Speciallicenses: Tcmponzy license -$75 pa quarter Limited license -$150 per Ssal year. Renewal:Biennialrenewal everytwo years,odd ycars-$155; AcademicLicense - $l50 14daylimited license -$75; SpeciaiVolunteer Limited license - no fee. . - CME Requirements:40 hours of AOA orAMA CategoryI CME evcry2 yrars,with a minimum of 30 hours related directlyto the Ucensee’spractice area and 2 hours of which must be in approved procedures of prescribingand monitoring of controlled substances. OCC/MOC not addressed,but the Board recognizesas equivalentto CMExcqtxIranents certificationof added qualificationsbr recertificationafter examinationby a nationalspecialtyboard rccogdzcd by the American Board of MedicalSpecialtiesorAindran OsteopathicMsociadon or another approved peth1ty board certification. Malpracticeinsurance: Not required

SOUTh DAKOTA EdudonaT Requirements:Primarysourceverificationfrom a Board approved AOA program PostgraduateTnidnr Applicantsas ofJuly 1,1987 must successMlycomplete an approved residencyprogram in its entirety which would be no lessthan 3 years. ards 6?.Os I DO, 2 non-physIcianmnnbers - Board Address:South akota Board of Medicaland Osteopathic Examiners, MargaretB. Hansen, PA-C,lWAS, CMBE, Executive Director, 101 N. MainAvenue, Suite301,Sioux Pails,SD 57104Phone (605)367-7781Fax (605)367-7786 jçhic Memben PhilipB. Meyer,DO Website:www4dbmoe.fov ExaminationsAccepted: COl.iEJ, NBOME, USMI$, FLEX IicenstFee: $400(2-yearrenewa FederationCredentialsVerificationService(FCVSbHighlyrccomma,ed Reciprocitytsr Endorsement: None Spedal licenses: None — there is no “inactive”licensestatus —iflicenseis not renewed, that licenseforfeitsby lawdue to non-renewal, Renewal:As ofjuly 1,2018, two (2)yearrenewalin odd numbered years;the initialreinstatement,andbiennialrenewallecensefees for physi4am wereallincreasedto $400as required. Offi Reouiremtits: None required for licenserenewal MalpracticeTnsunnce,Not required

F TENNESSEE EducationalRequirements:Graduation from recognizedosteopathic college Posp,,duate Tninlnq I yearAOA nrACGME training Bmrd: 5DOs, 1Publicmember gjrdAdslraa: Tennessee Board of Osteopathic Examination,AngelaM. Lawrence,MSM,ExecudvcDirector, 665 MainstreamDrive Nashville,TN 37243-0001,Nashviflc,TN 37243-0001Phone (615)532:3202 PLx(615)2534484 Ostenthic Members:MichaelWitting,DO;Jeffrey L. Hamrc, DO; Shannon Ki&elly,DO;Jan Day7ieren, DO; Shant H- Garabedian,DO thth hnp://tn.gov/healthftovic/osteo-board SunsetbwYes - Exaninatinna Accepted: COMLc NBOME for initial a reciprocallicensure - USICE and FLEX accepted for recijnodty only.The Board ujil accept any of the followingexaminationsor combinationsof examinations: (a) The NBOE a COMLEX or anycombination of their parts; or

21 -resident Salt Board flnassi Postnduts Eduational TITAn have Malpractice approved complied EMS professional acceptable CMP periods institution). in number Renewal: Sesedal Rccinmdty Federation recognised. certification MnillnSthl DzasnwhicLlenibrtrjames Orh.r ten TX Examinations Website: Batd g4: Educational rwnduate TEXAS Malpractice as Providers hours month CMI! the license Renewal: birthday talent Special Reciprocity Federation Jicense process). Lake substitute. years 78701 hospital calendar ( (g) (e) snediqal (4) (a) ) Addressa Ruirements: 4 Requiwmentr Requirements: Address: sbfl Licenses: training axe NUME 9 licenses NEME DOs; of renewal Combinations license. Pttdecessor FLEX FLEX Ucen,es, City, with by Initial www.tmh,stjtc,rx.us Fee: MDs, either £1, tomeet Biennial, Phone of the assigned Crcdend.Is Insurance: Requirements: Physicians Changes or Stats responsibffity be, the Tminir. examinatIon, Credentials Yes Insurance; $1017 privileges. Requirements: or Surgery, direction year. intractable Tnininr UT all Non-refundable I Accepted: pursuant flndonemer.t: license Utah Component Components program biennial 3 the Endorsement: pa public ARMS Dean Pan expire Tens at course CME Protidond enmimdons DOs,? 84111 (512) Training these licenses alcerniitive SPEX $305. by I Ostecpathic 12 I FLEX to Medial with’a 40 period. of orUSMLE 24 Not or in of member for Medical in Verification requirements the or other hours I Not 385-7010 to designed pemtit—$856, Verification requirements Phone pain program and hours COMLEçNBOME, tnining USMLE months yeas odd public the The On with the those the Degree 10 Texas required. license Days Graduation issued Iplts required passing license I continuing None Predecessor institutions nm,ziagernene credits internls ADA. jurisprudence “ScoW’ formal number for Dii’ also and due On-an application before Board, bf score (801) members who Physicians permit I, Medical specifically of Step Fax must ADA V.5,/Canada Step US?fl.E of under for clue H; completc Service Hand!!!; ion — ptogressiveACGME scorn However, Service if pain -$107 over DO CME 530-6628 registered individual must or — Holiday, (512) osteopathic Subsequent years. 1977. Stephen In which I . 1, of submit for see Category from on required plus the fee the plus management Board earned FLEX Health 75 fee on mug Step start license Qiniitedlicenseto (FC’l: (24 in Board 305-7051 exam & (?CVS’): Renewal unlquerraining alternative to - preceding withIn will NBM’E a college - or a $141 NEME Surgeons many bours application Brim gmduutes En address $410 specialty as USMLE, progressive DO; at basis 3; a: have Days from allow Related for I-A, (tens an biennial interns, renewal Rule the or the (801) Will 3 hospirals Carlton,jD, Kandace approved training Wall offline Part with ofAOA periods specialized attempts; beginning Part li-A 1,11 an time for 36 fox prescribing method for on licensing certification accept FLEX 530-6511 Boards ADA accept or hoc month, residents any to is those permlt—$8S2, medical and the 11 specifics; and/or of resident equal medical ADA its the if practice or are will Farmer, orAMA licensura other distribution by Ill nor USMLE or expiration approved axe all US.MLE who of board. CME “biennial Febmaq’ Executive to the require Board, the amen: rèsidem are pam practices, I-B laws otherwise valid the and training state director spedahy examination, 1 ptacticc for Board licensee not hour DO; in or process. Category in fellows; within Step Even for Step 270 pain laity medical AMA physIcians - date certification allowed Ts) 28, binhdate of training of George Director, program - twenty-four at must for 2 licensed days the in ccrtiacation 2pbs May management becomes the,fonnal number which the iIus 7 Marx, Category a.pain telemedicine an 1) years. license school maintenance in include with time 31, plus or EMS FLEX Dc renevnl to NEME a in is 333 Bureau - éompldoo medically by August31 clinic licenses Ten any any 1212 . Lone!., DO the board Utah. 12 workload (24) or service. ADA, ethics 1-A Guadalupe bistrudon if Component hours - last other Year (ADA college appmved or system.” Part medical (AOA (fee license; months, Manager, and certified DO MD expire of day must ARMS undcrserved A Rule informal coven III or examination. certification’ 2-A of 1-A as licensee of 1-A>nd degree November30— or malpractice 12 special uniformly be Street, in The in and Exception: by the every or or 160 It US?mESt or months all controlled in even board, recertified 2-A). month per Division American expire the conferred. training East shall volunteer Tower 2 1 ar number yeah years. nanminadon, area hour as OCC/MOC in COMVEX 300 insurance be on in Complete whe is an substance of at establishes MDC 3, presumed which of by Two practicable the these South, Board ACGME 3; the years ethics Suite license fonnal a flail last or specialty same may (4 registration a in of application and 610, not or 4 within day license and/or not of prescnbrng. order credit to Oral and be continuous’ Floor, a or odd throukl,out the Austin, of system accepted have AOA board locum the the to and 40 holder’s lii 22 last last is of

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approved

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1970

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24 their WISCONSIN Ethabonqi Renuirements;Graduadob froma recognizedosteopathiccollege Posigaduats TSirilny 2 yearsat an AOA or ACGME approved training facility - 9 ?.fl)s, 11)0,3 publicmembers Board Addresses:WisconsinMedicalExaminingBoard, Thomas H. Ryan,JD, MPA7Exccgtiveflirmctor,4822 MadisonYardsWay, Madison,WI 53705Phone (608)266-2112Fax (608)267-3816 Osteopathic MemberMaryJo Capcdice,DO Wabj: illgLflga! Sunset Law;No ExaminationsAcceoted:COWE, NBME;US?dLE, FIE 111CC (takenafter 1/1/78) state board examinationstaken prior to 1972 license Fee:Endorsement of NationalBoard CertificateQ’ThOME& NBM, FLEX, USMLE$150;Reciprocityof state board exam taken prior to 1972-$198; Endorsement of 111CC taken aftcrJanuary, 1978- 1150(allfce include $57jurisprudenceexamination).Oral exam,if required, is an additionalfee of $266 Federation CredentialaVedficadoiiService(FCVS1:Willaccxpt - Reciprocityor Endorsement:Endorsement on individualbasis;on! am may be required. Spedl Licrnces:VisidngProkssoriccnse - 1216 (indudrs jurisprudence);camp Physician-$216 çmdudas jurisprudence);LocumTenens -$216 (includesjurisprudence). Renewal:Biennial,March.1,even years - $141 CME Requirements:30 hours of AOA or AMA Category 1vcq 2 yearsobtained between March 1 evenyear and February28 evenyear. OCC/MOC not acceptedassubstitute. NOTE: On November 10,2016, emergencyrules went into effect that reviseWssconsin Admhuisüathc Code Chapter Med 13 to provide that twoof the required 30 hours of C?ffi for the mszrentblenniumand the IolIoà’ing biennium must be relatedto the opioid prescribingguidelineissued by the Board. Physicianswho do not hold a U.S.Drug Enforcement Administration number to jreictibe controlled substances are exempted under the rules. MalpracticeTesurance;Physiciansmust carryinsurancewith limits of $1,000,000per occuaence/$3,000,000 pa annualaggregate.

WYOMING Educational Reouircrnent,:Graduation from an AOA approved college PaatgzadiaiTninin 2 yearsin an AOA or ACGME accreditedpromns iphysicians (minimum2 Ds and I DO), 2 publicmembers, I PA Board Address:WyomingBoard of Medicine,Kevin I). BohncnblusçJD, CMBE,ExecutiveDirector, l3Oflobbs Avenue,SuiteA Cheyenne,WY 82002Phone (307)778-7053Fax (307)778-2069 Osrenwhic I’Jemhez:MelindaPoya, DO We,site: hrrp://wyonedboaxd.wvo.gov/ Sunset law; No Examinations Accepted:COMLEX,NEOMB, USMLE, FLEX LicenseFee: $600 Federation CredentialsVedlicationService(FCVl: Requital Reciprocitynr FMnnen*.t At discretionof board, personal intervi& & oral mminadon maybe required - SPElLmay be requhcd

Sntdaliicenscs: None - Renewal:Annual,June 30- $250 CME Requirements:BeginningJanuaq 1,2007, in order to renew,reinstate or reactivate a license,physicianimust complete60 hours of AOA CategoryI, Category2,1 current Physician’sRecognitionAward from the AMA, a current certificateiron anyAEMSboard every 3 years. OCC/MOC not accepted,.butphysiciansthat have within the past 3 years been certifiedor recertifiedby a member board of the ARMS am ocerupt Effectivejuly 1, 2019,physicianswho areregisteredwith the Road of Pharmacy to dispensca controllcdsubstancein the state are required to catplete 1 hour of CME related to.the responsibleprescribingof controlled substancesor the tratrnent’of substance abuse disorders every2 years. Malpndceinsunnre: Not requiredby state lawbut availablethrough the WyomingMedicalSociety.

US TERRiTORIES

GUAM EducadonatEcnuirements: Earned DO degree - certificateof proficiencyIn the basic sciencesis required,plus proof of not less than 1 year of trainingin a hospital registeredand/or acceptableto the Commissionon liceasure to Practicethe HealingAn. Board Address:Guam Board of MedicalExaminers, MarleneCarbullido,ActingAdministrator,Health Professionallicensing Office, 123 Chalan Kareta South Route 10, Mangilao,Guam 96913-6304Phone (671)735-7407Fax (671)735-7413 Websitc v,wgjp’ Poatgnduate Thinihsn 3 yn or beAEMS Certified. Examinations Accepted: USt5UE,NBME, FLEX, SUE,111CC,COMLEC - .jicense Fee Non-refundablefee - $400—(checksor moneyorders should be made payableto Treasurer of Guam) Falasion Cdaid,k3iedficuflon Service(FCV: Willaccept

25 Reciprocityor Endorsement:Possiblygranted on the basisof existinglicerne.SPEXrequiredunlessexamtakenwithin 10yearsor been our of pnctie for the past7years. CMERequirements;Musthavecompleted100C?ffi creditswithin the past 2 years (50%must be Category1)or completeACOME PFT withinthe past yeas

PUERTO MCD EducationalRcquirem:nts:DO degreefroman osteopathiccollegerecognizedby the Boardof Medial Examiners Bond Address:Puerto RicoBoardof MedicalUcensureand Disdpllne;1c2aTorres-Aguiar,ExecutiveDfrector,Junta Dr Ucendantiento V DidpEm Mcd,P.O. Box 13969,SanJuan, PR 00908Phonc (787) 999-8989Ext. 6579 Website,hrtp!//www2.ptaov/Pnes/defruksapx Pnstduatc Thinior lycar approved by Boarclj6 months uninterruptedresidencein Puerto Ricorequired Examination, Accepid: In Englishor Spanish,at option ofapplicant. US?.UE, NBME, FLEX, NEOME, COMLEC (‘snug coanpinte USMLEstep I, TIand UI uidiln 7 years of passingfirststep.) IAccnseFee: $150 Fedention Credenthl Ved&ition Service fFCV: Not accepted Retipraicy prEs]dnaement: For.unlimked license,ifgmnrcd by a us statehavingreciprodty withPuertoRico.SPEX not accepted. CME Requirement.: 60 bàurs every3 years;allmust be Category I

VIRGil’! ISLANDS EducationalRequitemcnts The licensingact governingthe health professions in the VirginIslands recognizesADA approved schools. Board Addrcst Virgin Islar.dsBoard of MedicalExarriners,Deborah IC Richardson-Peter,MPA,Director, Professional Uceosure & Health Planning,3500 Estate Richmond, Chñstiansted,VI 00802-4370Pbor.e (340)718-1311en. 3047Fax (340) 712-1376 Websht MedicalUcensure Requirements Postnaduatv ttnining 1yearADA ‘orAMA approved training E,camination,Accepted: USMEE,NBME, FLEX SBE,LMCC,NBOME, COMLEX, SPEX :eqi4rth of aDapplicants plus oral exams must be takenin Virgin Islands,(must comptete USMLEstep 1,11,and III within7 yearsof passingthe first step.) Ucense fee:$800 (exam) Racinr&ry or Endorsement None Federation CredentialsVedflcatinnService(FCV: Required Renew1: $500 CME Requirements: 25 hourseveryyear;allmust be CategoryI

26 NATIONAL BOARD OF OSTEOPATHIC MEDICAL EXAMINERS. INC

The Naional Board91OsteopathicMedicalExaminersO’JBOM is incorpoatd under thelawsoldie staleof Indiana.It coosistsof dot more dun 25 membersat-largehorn the osteopathicprofession.Membersmust be osteopathicphysiciansin goodstandingof the AmericanOsteopathicAssociation,cducators/cliniciansof recognizedprominenceand shallhavebeenlicensedto practiceas an osteopathicphysicianfor at least fiveyearsprior to appointment.

Boardmembersare nominatedby the directorsof the NationalBoardof OsteopathicMedicalExaminers,approvedbythe Boird of Trosteesof the AmcriczinOsteopathic Association1and electedbytheNadonal Boardof OsteopathicMedicalExaminers,to servefor a pedod of tifreeyears.

- The officersof the Board consist of a President/CEO,ChiefOperationsOfficer,VicePresidentofTesting& Researchand Secrcary Trcasurtr, sclcctd from and elected by the membershipof the Board at each spring session,and serveuntil their successors arc qualified and elected.

The Board has establishedan advisorypanel or tat conunittee of content experts far each examination.These experts must be duly nominated bya member and approved bythe Board.They are appointed annuallyto serve under the direction of the respectivetest constructioncommittee chainngn.

REGULATIONS AND REQUIREMENTS

The ComprehensiveOsteopathic MedicaiLicensingExaminatiosi(COMLEX-USA)examinationis dividedinto three levels.th the exceptionofLevel2—PE, allparts of the examare computer-based.

COMLEX-USALewd I Constructedaccording to the COMLEX-USAexaminationblueprint.Candidatesare expectedto demonstratebasicscienceknowledge relevantto medicalproblemsas definedbythe Level1 blucpdnt,LevelI emphasizesthe scientificconceptsandprinciplesnecessaryfor understandingthe mechanismsof hcalth, medicalproblemsand diseaseprocesses.

Level1,eakenin one-day,Isa probleni-and symptom-basedassessmentintegrating he basicmedicalsciencesof anatomy,behaviors] science, biochemistry,microbiology,osteopathicprinciples,pathology,pharmacology,physiologyandotherareasof medicalknowledgeas they are relevant to solvingmedicalproblems. The examination consists of two four-hour test sessions1 eachcontaining questions related to diverse clinicalpresentations and principles.

COMLEX-US&Level2 - CO)Vff2JCLeVel2 consists of two-parts the CognitiveEv uation (CE) and the PerfosananceEvaluation(PE):

CO?.CEX-IISA Level2-CR Constructed accordingto the CO)vIEXJISA examinationblueprint.Candidatesare expected to demonstrateknowledgeof clinical cootepesand pdndplea involvedin all steps ofn,edicalproblem-solvingas definedbyDimensionII.Level2-CE emphasizesthe medical conceptsand principlesnecessaryfor maldngappropriate medicaldiagnosesthrough patient historyand physicalexamination findings.

Level2-CE,taken iii one-day,is a problem-basedand symptom-basedassessmentintegrating the dinicil disciplinesof emergency medicine,familymedicine;internal medicine,obstetrics/gynecology,osteopathic principles, pediat&s, psychiatry,surgery,and other areas necessaryto solvemedicalproblems as definedbythe Level2-CE blueprint.A similarproblcm-symptnmbased approach is used in Level2 and in LevelIThe examinationconsists of two kurrhour test sessions,each containing questionsrelatedto diverseclinicalpresentations and principles.

COMLEX.USALevel 2-PE For caseselection,Level2-PE appliesthe Dimension! categoriesfrom the COMLEX-USA blueprint.The contasi (caseselection)of Level2-PEis crossed with the followingaxes:

Patient Presentation Ais Standardizedpatients presentin simulatedambulatorymedicalsettingswithproblemsand symptomsthatare tidier acute,chronic,or provideopportunitiesfor healthpromotion and diseaseprevention.In addition,±c patithts encounteredare balanced to meet the examinationspecificationsforpatientgenderandageasa reflectionof nationalosteopathicphysicianpracticepatternsbasedon national surveydab aswellas expertjudgment.in addition,the demogr2phipand cultural profilesofpatientsareinstrumentalconsidendons in the casedevelopmentprocess.

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- 28 ELIGIBILITY REOUTREMENTS

COMLEX-USALevel I . A candidatçis eligibleto take the COZCEX-USALevel I crarnination upon compliancewith the followingrequirements:

1. Musthave satisfactorily completedthe nt half of the secondyearin a medicalschoolaccreditedby the American OsteopathicAssociation’sCommissionon Osteopathic CollegeAccreditation(ADACOCA). 2. Must be in good standingwith a medicalschool accredited by the ADA COCAwhen application for the examination is made and the examinationis administered,or must havegraduated from a medicalschool accreditedbythe ADA COCA. 3. Must havehis or her name submitted by the office of the dean or his or her designateas eligibleto test in order to register

online.Alternatively,if the candidate has graduated,a notarized copy of his or her medicalschool diploma willbe accepted. -

COMLEX-USALevel 2-CE (Cognitive Evaluation) A candidateis eligibleto take the CO?ilEX-USA Level2-CEexamination upon compliancewih the followingrequirements:

L Must havepassed Ihe COtvfl..EX-USALevel I examinationwithin the NBO?fE requirements. 2. Must have satisfactorilycompleted the ihurdyearin a medical school accreditedby the AOA COCA. . 3. Must be in good standingwith a meical school accredited by the AOA COCA when applicationfor the examination is made asidthe examinationIaadministered,or must havegraduated fom a medial schoolaccreditedby the AOA COCA. 4. Must have his or hcr name submitted by the office of the dean or his or her designateas eligibleto test in order to register online.Alternatively,if the candidate has graduated,a notarized copy of his or her medicalschool diploma willbe accepted.

COMLEX-USA Level 2-FE (Performance Evaluation) migibifityrequirements to take COMLEC-US Level2-PB are !denticalto those required to take CO?vLEX-USALevel 2-CE (see above). However, candidate, who are unsuccessfiflin passing COMLD(-USA Level2-PB cannot re-take the examinationfor a period of 90 Ml days after their prior exanilnadondate, and mayonly ru-takethe examinationa maximum of three times in any 12-month period. COMLEX-USALevel2-PB may be takenbeforeor after COMLEX-USALevel2-CE Both COMLEX-USALevel2-CE and COMLEX USALevel2-PB must-bepassed independentlyin order to establisheligibilityfor COMLEC-USALevel!. COMLEX-USA-Lcvel3 A candidateis eligibleto take the CO?.fi.EX.USALevel 3 examinationupon compliance with the followingrequirements:

I. Must havepassed the COf4EX-USA Level I, COMLEX-USA Level 2-CE and Level2-PB examinationswithin the - NEOME requirements 2- Musthavegraduated from a medicalschool accreditedbythe AOA COCAwith an earnedD.O, degree. 3. Must be currentlypaxtidpatingin and in good standingwithan AOA Post graduate Education andTraining Review Committee (PTR approvedinrernship or ACGME-approvd PGYI, or must havesuccess&flycompleted such an internshiporprbgrant Must submitverificationfrom the Director of MedicalEducation or ProgramDirector that the candidate1,in good standingwithan AOA Post graduate Education and TrainingReviewCommittee (PTRQ approved internship or ACGME-approved PGYI. Can teewho have completed an internship orprogram must submit a notadaed copyof the internship certificateor PGY1 certificatein lieu of the vedflc3tlonof good standing.

As ofJuly 1,2004, all candidatesarc required to pa!s COMLEX-USALevel 2-PB as a condition for eligibilityto take COMLEX-USA Level!, with the exception that candidateswho graduated from a collegeof osteopathi&medicine accreditedby theAOA COCA prior to January 1,2005 willbe exempt from the requirement of pasting COMLEX-USA Level2-PB if theypass COMLEX-USALevel 2-CE prior toJune 30,2005. Allother COMLEC-USALevel 3 eligibilityrequirements reMainin effect.In addition,candidateswho are unsuccessfiil in passing COP.[LEX-USALevel 2,PE cannot re-take the examinationfor a period of 90days from theirprior examinationdate, and may only re-takethe examinationa maximumof three timesin any12-month period.

The COMLEX-USALevelsmust be taken in sequence.For aemple Level2 cannot betakenbeforeLevel1. Hdwever,Level 2-CE and Level 2-PB maybe taken in any sequence.If a candidatehas failedthe CE Examination, he or she maystillchoose to take the PB Examination,and if the candidate has failedthe PB Examination, he or she may still take the CE Examination.Both the CE and the PB Examinations must be passedin order to take Level3.

REGIWThATIQNJNEQRMATION - . - -

Registntion/ Scheduling - AUcandidatesmust use thç online registrationsystem to: register/pay for an examination, schedule or reschedulean examination,canel or withdraw from an examination:receiverefunds or credits, obtain the schedule of test dates,and choosea locationat which to test. It Is also where the candidatewillEnd the thbst current information about policiesand procedures applicableto testingand other items of interest to candidates.

29 r

Registration Code After a listof candidatesapprovedto rake the COMLEX examinationis receivedbythe NBOME from the.dcan of an catcepathic school, an li-digit securecodewillbe mailed to each candidate.This code is required onlyfar the first accessto the registration system at the NEOME website(www.nbomc.or.

NEOME Reglatradon Upon cattyof the registrationcode,a candidatewillbe prompted to createausaname and a passwordand verifypersonalInformation. Registrationwillbe completedoncepaymentby creditcan]has been enteredand approved.Paymentmust be completed onlinewith a creditcardbeforean examinationdate can be scheduied.

Scheduling an Examination Date and Test Center Followingregistrationat the NEOME website,a candidatemay schedulean onmlnation date (appointment) through the NEOME website.(Pleasenote that there may be a slightdelay betweenregisteringwith the NBO1.ffi and the abilityto schedule an examinationdate on the NBOME website).Candidatesmay registerand schidule an examinationas earlyas sb ( months in advance eta scheduled test date for COMLEX-USALevel1, Level2-CE, or Level3, and up to 12months in advancefor COMLEX-USALevel 2-PE provided that theyare eligible.Candidatesarc stronglyadvised to schedule at least 90 daysbefore their desired test session to maximize the chance of obtainingtheir desired testingdate and site. Candidates may not schedule a teat less than 120bows in advance of the session test date under any circumstances.

COMPREJ&ENSWE OSTEOPAVflC MEDICAL VARIMLE PURPOSE EXAMINATION - USA (CQMYEY-tJS

The COI.WEXisaninstn,mentoffered to osteopathicphysicianswho need to demonstrate currentosteopathicmedicalknowledgefor licensingpurposes.Ass measurementtool, the COMVEXprovides the statemedicallicensingboardswitha clear evaluationof a candidate’sknowledgeof oanênt osteopathic medicalpractices.

The CO?vWEXis availableto candidatesthroughthe individualstatelicensingboadL The examinationis createdunder the auspicesof the NationalDoard of OsteopathicMedicalExaminers by test construction and reviewcommitteesccrnpuicd of a variety of osteopathic physiciansfrom a range of medicaldisciplines.

SPECIAL PURPOSE SCAMINA7ION fWEXI

The Federation ofSnte.MedlcalBoards administersthe SpecialPurpose Examination GaTEX).The.purposc of SPEX is to re.aamine specificphysicianskr whom a licensingboard dcteanines the need for a demonstadon of medicalknowledge.It isa onc.day examination composed of multiple choicequestions,which arc speciallyselected to test physicianswho are fiveor more yeats beyond medical school graduation.

30 Attachment P c,J OWe

CU. CoC — a o 15

D 113

C) CD r rCO 0CD c’i’ c C) o U, r Ct) •D ES Esr o —

U • — -c 4-’ Ct 0a - a, 3-’ 0 0 0a, - o C U- II—o aa,

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x >1 .! 0 to a, C 0 to to 00wd Cu CC) ‘I-’ c C C C Co 0 a, a, th E c V V Co a, a, a, o ‘I-’0 0 o o a, — 00 aI- aI- a- STATE BOARD OF OSTEOPATHIC MEDICINE RENEWABLE LICENSEE COUNTS 14000

12000

10000

8000

6000

4000

2000

0 P12018/2019 CURRENTLY P1201912020

- Licensees 9809 - - 11114 - 10435 11714 11774j 12701J —

LICENSEES BY CLASS P117-la FY1B-19 P1 19-2a Osteopathic Physician & Surgeon 8,722 8,651 9,009 Osteopathic Physician Assistant 1,930 2,130 2,603 Osteopathic Acupuncturist 109 106 110 Osteopathic Respiratory Therapist 551 540 560 Osteopathic Perfusionist 37 30 39 Osteopathic Physician Acupuncturist 46 45 49 Osteopathic Genetic Counselor 9 11 25 Osteopathic Athletic Trainer 260 261 326

TOTAL 11,714 11,774 12,721

2 State Boaril of Medicine W2f2020 EKpense and Revenue History Comparison

. Actual Athial Actual Actual Actual Actual Actual Actual . Ezpen.á Ezp.nns Expenses Expenses Expenses Expense Expenses Expenee. ‘ ‘ Co.tCen6c FT 12-13 fl1344 FT 14-15 FYID 15-la PYle-ti FT 11-lB FT 18.19 FUD 1-20

BPOAAdmlnlstmtlon 102,876.45 280.02521 242,986.66 347,064.44 262,615.50 376,675.26 493.03107 250,413.51 Conmisslona?s Difice 9,024.05 9,361.24 6,989.78 8,035.63 10,399.62 11,007.02 11,391.49 0,244.95 Revenue Office 4,037.94 4,977.46 4,936.70 5,247.37 5,551.89 4,891.86 4,664.78 3,425.01 Depaittiental ServIces 48,430.54 26,315.33 50,062.12 56,000.00 51,098.66 56,398.46 67,000.00 58,000.00 BosrdMember 9,034.45 12,647.79 10,286.45 9,211.47 11,365.32 11,540.85 11,599.57 9,642.03 Legal Mmlnlsfltlon 383,097.89 462,356.69 509,116.61 29,150.28 9,533.14 5.76028 12,582.91 18,452.43 Prosecution 62,72724 67,038.19 56,226.59 462,520.71 529,774.90 486,72628 521,616.73 345,591.00 Legal Counsel 0.00 0.00 0,00 68,520.99 81,183.98 149,425.88 136,861.01 134,119.58 Hearing E3pefns 25,633.00 50,377.85 36,314.54 91,943.32 83,979.53 02,760.56 69,978.00 52,219.69 BureauofEnforceownt&lnvsstigstion 299,742.67 337,897.04 236,670.76 322,122.12 416,272.65 388,785.54 500,339.32 320,716.67

PHMP 61,175.67 66,255.60 07,082.79 - 102.095,21 92,363.04 100,873.14 118,120.80 80,291.42

TOTAL 1,006,000.00 1,317,253.40 1,248,673.20 1,522,811.54 1,554,19823 1,657,945.13 1,935,185.74 1,279,116A0

, Actul Actual Actial Actual Actual Actual Actual Actual t Rnue Rsenue Reue Renue [‘i’R.variue Rnue Revemje I Reven00

- - -, P114-IS .- J;%’hvenueaysoume fl12-13 P113’14 FYfl-18 [ P116.17 FYIT-IB 1 P11849 J FyTh4/30120

Renewals 1,617,771.00 41,171.00 I,716,031.50 33,482.50 1,802,565.00 32,721.00 1,901,513.00 35,595.00 ApplIcations 57,620.00 69,855.00 74,150.00 77,632.50 103,605.00 ios,sga.oo 90,474.00 85,919.00 Letters of Good Standing 17,100.00 19,440.00 18,370.00 22555.00 22,230.00 25,105.00 27,805.00 18,650.00 Civil penaltIes 2,505.00 7,250.00 2,700.00 8,200.00 5,100.00 4,043.36 16,039.00 6,000.00 Act 48 CitatIons 0.00 250.00 0.00 0.00 0.00 0.00 0.00 0.00 InvestIgations 0.00 0.00 515.52 619.80 0.00 7.66L23 0.00 0.00 Licensee Lists 13,359.62 13,794.49 8,700.90 14,926.66 9,870.97 9,665.58 10,201.60 9,895.20

TOTALREVENUE 1,708.355.82 151,760.49 1.820,475.92 157,816.46 I,943,370S7 184,890.17 2,046,122.60 156,05920 State Board of Osteopathic Medicine 6/2)2020 No Change

CURRENT TOTAL UCENSE RENEWAL RENEWAL Last fee increase 2004, Board fee decrease 2009 LICENSE CLASSES COUNT FEE FEES

Osteopathic Physician & Surgeon 9,009 $ 220.00 $ 1,981,980.00 Osteopathic Physician Assistant 2.603 $ 10.00 $ 26,030.00 Osteopathic Acupuncturist 110 $ 25.00 $ 2,750.00 Osteopathic Respiratory Therapist 560 $ 25.00 $ 14,000.00 Osteopathic Porfusionist 39 $ 50.00 S 1,950.00 Osteopathic Physician Acupuncturist 49 $ 25.00 $ 1,225.00 Osteopathic Genetic Counselor 25 $ 75.00 $ 1,875.00 Osteopathic Athletic Trainer 326 $ 37.00 $ 12,062.00 12,721 TOTAL RENEWAL REVENUE: $ 2.041,872.00 TOTAL NON-RENEWAL OTHER REVENUE: $ 296,877.00

TOTAL BOARO REVENUE: $ 2,338.749.00

9o1a1 anticipated applicants over a biennial period.

Actual Actual Projected Projected Projected Projected Projected Projected Projected FINANCIAL STATUS FY Il-IS FY 18-19 FY 19-20 FY 20-21 FY 21-22 FY 22-23 FY 23-24 FY 24-25 FY 25-26

Beginning Balance: 3,194,739.49 1,712,593.53 1223,530,39 400,530.39 586,530.39 (1,064,469.61) (937.469.61) (2,643,469.61) (2,577,469.61)

Revenuo: 154,599.17 2,046,122.50 187,000.00 2,152,000.00 157,000.00 2,152)000.00 187,000.00 2,152,000.00 187,000.00

TotalAvallable: 3,379,638.66 3,758,716.13 2,010,530.39 2,552,530.39 773,530.39 1,007,530.39 (750,469.61) (491,469.61) (2,390,469.51)

Expenses/Budget: 1,667,045.13 1,935,185.74 1,510,000.00 1,966,000.00 1,638,000.00 2,025.000.00 1,893,000.00 2,086,000.00 1,950,000.00

Remaining Balance: 1.712.593-53 1,823,530.39 400,530.39 586,530.39 (1.064,469.61) (937,469.61) (2,643,469.61) (2.577,469.61) 14,340,469.61)

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Osteopathic Physician & Surgeon OsteopalhicPhplan&SuigeonApp 1200 2.409 5 45.00 $ 108.00000 1.200 2.400 $ 170.00 5403.000.00 1,200 2,400 S 185.00 $444000.00 1.200 2.400 5205.00 $492,000.00

Graduate Osteopathic Trainee Graduate Osteopathic Trainee App 600 1.200 $ 30.09 $ 36,000.09 600 1200 $ 115.00 5138.000.00 600 1.200 S 125.00 5150.090.00 600 1.200 $14009 $168009.00

Oateo RespIratory Therapist License Osteo Respbatorymerapist License App 50 109 $ 30.00 $ 3,00000 50 109 $109.00 $ 10,00000 50 100 $ 110.00 $ 11,000.00 59 100 $120.00 $ 12,090.00

Physician shoft-lein camp License Temporary Osteo Physician License App 60 120 S 30.00 $ 3,600.00 60 120 $ 100.00 $ 12,000.09 60 120 $ 110.00 $ 13,200.00 69 120 $120.09 $ 14.40000

Ostao Physician Assistant License Oaleo PhyslcianAaaislanl LicenseApp 500 1,000 S 30.00 $ 30,000.00 500 1.000 $115.00 $115,000.00 500 1.000 $ 125.00 5125.090.00 500 1,000 $ 140.00 5140,000,00

Physician Acupuncturist Oslen PliysldanAcupunclurislApp 6 16 5 30.00 $ 480.00 8 16 $100.00 $ 1,600.00 8 16 $ 110.00 $ 1.760,00 8 16 $120.00 $ 1,020.00

Supervising Physicien WrlUen Agreement OsteoWdtten AgreemeitApp 51 102 S 95,00 $ 9,590.00 61 102 $145.09 $ 14,790.09 51 102 $ 160,00 S 16.32909 51 102 $175.00 $ 17,850.00

Aiblelic Trainer OsteoAthletlc TnlnecApp 80 160 S 20.00 $ 3,200.00 80 160 $100.09 $ 10,000.00 00 160 $110.00 5 17600.00 80 160 $120.00 $ 10209.09

Genetic Counselors Gw,etlcCmmsslorsApp 10 20 S 50.00 $ 1,000.09 10 20 $ 120.90 $ 2,409,00 10 20 $ 130.00 5 2,600.00 10 20 S 145.00 $ 2,900,00 GeneicCounselors Reathyation App 5 10 5 50.00 $ 500.00 5 10 5105.00 $ 1,050,00 5 10 $115.09 S 1,150.00 5 10 $ 125.00 $ 1,250.00 Tranporary Provisional GenetcCounsolom 15 30 S 50.00 $ 1,500.00 15 30 $ 90.00 $ 2,700.00 15 30 $ 100.00 $ 3,000.00 15 30 $105.00 $ 3,150.09 Acupuncturist Osteo AwpundudsiApp 5 10 $ 30.00 $ 300.00 5 10 $100.00 $ 1,000.00 5 ‘10 5110.09 $ 1,100.00 5 10 $120.00 $ 1,200,09 Osiso Perfuslontat OateoPedusloolst4p ID 20 $ 50.00 $ 1,090.00 10 20 $120.00 $ 2,400.00 10 20 $ 130.00 S 2,600.09 10 20 5145.00 $ 2,000.00 Oeteo PethisionlstReadivalion Fee 5 10 $ 50.09 $ 500.00 5 10 $105.00 $ 1,050.00 5 10 $ 116.00 S 1,150.00 5 10 $125.00 $ 1,250.00 OsleoTempwaryGnduale PethjsionistApp 1 2 $ 50.09 $ 100.00 1 2 $120.00 $ 240.00 1 2 $ 130.00 S 260.09 I 2 S 145.00 $ 290.00 OsleoTnpomyoraduetePwfu&ordst-PmvI&onalApp 3 5 $ 40,00 $ 200.00 3 5 $ 60.00 $ 400.09 3 5 $ 88.00 S 440.00 3 5 $ 95.09 $ 475.00

ToWs 2,603 $ 199,070,00 1726,630.00 5791,180.00 5875,785,00 PA VT WV ME Osteopathic Physician Initial Licensing $45 $500 $400 $350 Renewal Fees $220 $350 $400 $500

Information based on chart provided by: The Knee Center for the Study of Occupational Regulation.

Cost for Application/Licensure for Surrounding States

1000

800

600

400

200

0 PA WV VT ME

Ii (ritizi Uc. Cost a Renew Fee per siennial Yr

-Nine north east region states do not have a separate ocnipadonal license for an osteopathic doctor or osteopathic medical practices. These states use the same licensing board for Osteopathic Medicine and Medicine. Usually this combined medical board issues a Physicians or Practitioners license and the physician determines whether they practice as an Osteopathic Doctor or Medical Doctor. The department that issues these licenses varies from state to state. Note: Compared to (he states that do have separate licenses for Osteopathic Doctors, PA has more continuing education hours required than the average.

- Renewal cycle; The four north east region states that license osteopathic doctors separately (including Pennsylvania) have a biennial renewal cycle. -Tlüs report does not include osteopathic acupuncturist, osteopathic genetic counselor, osteopathic perfusiotüst, osteopathic physician assistant and osteopathic respiratory therapist. To see the data on these occupations please see the Board of Medicine report. FEE REPORT FORM

• . Agency: State - BPOA . Date: July 22; 2019

Eontact: ICKaionjiJobnsti; Acting Commissioner Bureauof Professional&OccupafloñalAffairs

Phone No. 783-7194

Fee Title, Rate and Estimated Collections: -

OsteopathicPhysicianand SurgeonApplication. . $170.00.

Estimatedyearlyrevaine; $204,000 - (1200applicationsx $170.00)

Fee Description: Theiqe will be chargedto every applicantfor an OsteopathicPhysicianand Surgeon liôense. - .

‘Fee Objective: The fee should(1) oflet the identifiablecosts incurredby the Stati Board of Osteopathic Medicinetp processan applicationand (2) defray apo±on of the Board’sadministrative overhead.

Fee-Related Activities and Costs: . .

Stafftime-processapplication (1.51w) . - $73.81 BoardAdminisratorrevieW (i5hr) $16.96 BoardMtomey review (.251w) .. $26.86 BoardMemberreview (.251w) $26.00

Transactionfee . $4.04 AdministrativeOvethead: $18.00 Total EstimatedCost: $165.69 • . ProposedFee: $170.00 for Program. application be

application

makes research disciplinaxyflegal to staff reviews documents respective

any files manually scores, Board

Analysis, an

issued, is

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miscellaneous

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State

applications

Board’s

Ostëopathiá

July22,

Board

administrative

2019

Osteopathic

$26.68 £97.52 $100.00 $13.00 $16.96 S2.38 $1130 $26.00

Physician.

$100.00)

$100.00 be for PMgram. application application research staff disciplümiyfleg&

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a S

FEE REPORT FORM - . -

• Agency: State-BPOA Date: Ju1y22,2019

• Contact: K.KalonjiJohnson,ActingCommissioner Bureauof Pmfcssion&& OccupationalAffairs

PhoneNo. 783-7194,

Fee Tifie, Rate and Estimated Collections: Gtduate OsteopathicTrainee License

or TemporaryTraininglicense; . . S115.00

• Estimatedyerly’itvenuer $138,000 (1200 çplicafio s x $115.00)

Fee Description: . The feewill be chargedto everyapplicantfor a GraduateOsteopathicTrainee or • TemporaryTraininglicense;

Fee Objective: . The fee shoula (1) offsetthe identifiablecastsincurred by the StateBoardof Osteopathic Medicineto processan applicationand (2) defray-aportionof the BoarcPsadministrative

• overhead.

Fee-Related Activifiesand Costs: -

Stafftime-processapplicétion - (.5hr) $24.60

BoardAdministratorreview (.25hr) $16.96 - • ,. BoardAftàrneyreview (.2Tht) • . $2688

- Board Memberreview (.2Sbr) ‘ $26.00

. Transactionfee • • $2.71

AdminisfrafiveOverhead: • ‘ . -. $14.00 ToialEsfimatedCost: $iii.is PmposedPee: $115.00 •

application for.scawiing. Program. research makes respective application to discipliñaiyflegal staff reviews docua maiiualiy It scores, files any Board Analysis, an

evaluating

issued,

Osteopathic

recommended

miscellaneous

to the

exits

appropriate

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supporting

staffissues

input

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clearance are

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of the

date

thaf .

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Board’s

$115.00

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Board a

system. are

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etc).

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Temporay

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possibly established

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The The Fçe Fee

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Phone

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fee fee

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offset and

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Estimated.

the

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Johnson1

every

and

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FEE

$57,500

Costs:

Applitation: applicant ..

and

Acting

REPORT

Collections:

(2)

costs

OccupationaL

for

Commissioner defray

Total

(.2Shr) (.25hr) (25hr)

(.5hr)

incred

Osteopathic

Estimated

FORM

Proposed

portion

Affairs

the

(500

Date:

Cost:

Fee:

Physician

State

the

appliàaions

Board’s ‘

July

Board .

A’ssistant

22,

administrative

2019

Osteopathic x

$111.15 $115.00

$14.00 $2.71

$26.00 $26.88

$16.96 $24.60

$115.00

$115.00)

license. Program. be for research

application application staff disciplinary/legal to reviews documents makes any scores, manually respective fles Board

It an Analysis,

issued, evaluating

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to I. • Mminisfradve Board Board Tnnsacfion Board • Staff Fee-Related overhead. Medicine Th Fee The Fee Estimated Fee Written Phone Conflict: Agency:’ tee fee time-process Objective: Description:

Title, Mânbei Attorney Administrator No. should will Agreement to yearly fee process Rite be Overhead: Activities review (1) review Bureau 783-7194 charged K. State revenue: application KaloUji offset and Application: an ieview. - BPOA of application

to H: Estimated the Professional Johxmon, every

and identifiable

FEE . $72,500 applicant Costs: and Acting

REPORT Collections: & (2) costs Occupational for defray Commissionr Total (251w) (.251w) (.Shr) (lbr) a incurred Written . a Estüated. portion Proposed

FORM - by Affairs Agreethezt the - of (500 Date: Cost Fee: the State • applications BoaM1s * July22, BDaId license. •. administrative

of . , 2019 Osteopathic x $145.00 $140.48. $3.43 $18.00 $26.00 $1696 $26.88 $49.21 $1 S145.00 45.0O) * •1

•

for be

application Program. research disciplinary/legdl staff application

makesappropriate documents to reviews

any

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scores, Written

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is issued, evaluating

scanning.

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recommendedthat

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review

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require are

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must

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Fee

Fee The Estimated

AcupunchiristApplication:

Fee

Agency: Phone

Contact:

fee

time-process Objeëfive:

Description:

Tide,

Member

Attorney

Adminisfratorrevicw

No.

should

will

yearly

fee

process

Rate

review Activities Overhead:

(1)

783-7194 K. Bureau

review

State

charged

revenue:

application Kalonji

offset

and

an -

BPOA

application

Estimated

the

Professional

Johnson,

evay

and

identifiable

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$500

Costs: applicant

and

Acting

REPORT

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(2)

costs

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for

defray

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(.2Shr) (.2Thr) (25br)

(.2Shr)

incurred

Acupuncturist

Estimated

portion

FORM

Proposed

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the

Date:

Cost

Fee:

the

State

applicati6ns

license.

Board’s

July

Board

22,

adminisftatjve

of .

2019

Osteopathic

$100.00)

$100.00

$14.00

$26.00 $2.40 $26.88 $16.96

$12.30 b

Analysis, Comment, and Recommen4ation: It is recommendedthata fee of $100.00be establishedforprocessingan application for anAcupuncturistlicense.

Board Staff — Staff opens, date stamps, and distributes mail. Paper applications are manually input into the licensing system. Staff downloadssupportingdocuments (exam scores, letters of good standing, eta). Staff matches supporting documents with the respectiveapplication,or createsa miscellaneousmail numberin thelicensingsystem and files the suppbftingdocuments. Beforeevaluatingan application,staffmust find and pull any miscellaneousdooumentsreceived in the office prior to the application. Staff then reviewsthepplicaflon by ensuringall documentsan received,completeand correct. Staff makes appropriatenotationsin thp applicant’s file though the licensingsystem. ff’ documentsarenot receivedand/orarc inconect, staffcreatesandmailsa letter, In addition to evaluatingthematerialsreceived,applicationsmay requirestaff to complete additional researchorderance reportsonline.Applicationswithdiscijilinary/legalissueswill require staff to reviewlengthylegaldocuments.When complete,staff forwardsapplications with disciplinary/legalacfionto theBoard’sLegal Counselforreview.Counselmay request the application be reviewed by the Board or possibly the ProfessionalHealth Monitoring Proáam. For applications that require Board review, staff prepares and scans the applicationto be placedon theBoard’s meeting agenda,Whenan applicationis ready to be issued,staffissuesthelicensethroughthe licensingsystem,andpreparesthe application forscanning. -Administrative

Boanl Transaction Board Board

Fee-Related

Staff Medicine overhead. Fee The

The license. Fee Estimated

Physician

Fee

Phone

Agency: Contact

fee

Objective:

time-pmcess Description:.

TiDe,

Administhitor Attorney Methber

No.

should

will

Acupuncturist

yearly

fee

proce$s

Rate

Activities Overhead:

review

(1) Bureau 7S3-7194 K.

State review

charged

reenue:

application

Kalonji

offset

and

review -

BPOA

application

Estimated

the

Applicatiorn

Professional

Johnson,

every

and

identifiable

FEE

$800

CostS: applicant

and

Acting

REPORT

Collections:

(2)

costs

Opcupafional

for

defray

Commissioner

Total

(.2Shr) (2Thr)

(25hr)

(.25hr)

incuired

Osteopathic

Estimated

portion

FORM

Pwposd

Aaks

the

Date:

Physician

Cosb

Fee:

State the

applications

Board’s

July27,

Board

Acupuncturist

administrative

2019

Osteopathic

$100.00)

$ibo.oo

$98.54

$14.00 $26.00 $2.40 $16.96 $26.88 $12.30

oa.oo - • S

Anaysis, Comment,. and Recommendadon It is recommendedthata fbeof $1OO.QObe establishedforprocessingan applicatiot for an OsteopathicPhysiöianAcupwictithstlicense.

Board Staff — Staff opens, date stamps, and distributes mail. Paper app1cations are manually input into the licensing system.Staff downloadssupportingdocuments (exam adores, letters of good standin& ete), Sthff matches supporting documents with the resp&rve application,or createsa miscellaneousmail mmiberIn theliàcnsffigsystemand fles the supportingdocuments; Beforecvaluatingan applicatioh,staffmüstfind and pull any miscellaneousdocumentsreceived in the office prior to the application.Staff then reviewstheapplicationby ensuringall documentsarereceived,completeandcorrect, Staff makes appropriatenotaflonsin the applicant’s file though the licensing system. If any documentsarenot receivedand/orareincorrect,staff createsandmailsa letter. In addition to evaluatingthe materialsreceived,applicationsmay requirestaff to completeadditional researchorclearance reportsonline.Applicationswithdisciplthaiyflegalissueswill require staffto reviewlengthylegaldocuments.When complete;staff forwardsapplicationswith disciplinary/legalacfionto theBoard’sLegalConnsçlfor review.Counselmayre4uet the applicationbe reviewed by the Board or possibly the ProfessionalHealth Monitoring Program. For applications that rcqufre Board review, .staffprepares añd’sbans the applicationto be placed on the Board’smôetingagenda Whenan applicationis ready to be issued,staffisazesthelicensethrouàhthe licensingsystem,andpreparestheapplication

fbrscawñng. • Administrative

Transaction

Board $oard Board

Fee-Related Staff Medicine

overhead. Fee The

The Fee

Estimated

Respiratory Fee

Phone

Agency:

Contact:

fee

time-process Objective:

Description:

Title,

Member Administrator Attorney

should

will

No.

yearly

fee

process Therapist Rate

Activities Overhead:

review

Bureau 783-7194 K. (1)

review charged Sate

revenue:

application

Kaionji

offset

and

an review -

Application:

BPOA

application

Estimated

the

Professionil

Johnson,

every -

and

identifiable

FEE

$5000

Costs: applicant

and

Acting

REPORT

Collections:

(2)

costs

Occupational -

ffir

defray

Commissioner

Total

(.251w) (.251w) (.251w) (.25hr)

incurred

Respiratory

Estimated

FORM

Proposed

portion

AfThim

the

(50

Therapist of

Date:

Cost:

Fee:

State

the

applications

Board’s

Board

July

license.

22,2019

dminisfrative

Osteopathic

$98.54 $100.00 $14.00 $109.00)

$2.40 S26.00 $16.96 $26.88

$12.30

$100.00 r

•

be for application

Program.

staff diEciplinaqflegal applicaff research to reviews makes respective documents files any

manually

Board. seorcs Respiratory

It Analysis,

issued, evaluating

scanning.

nijacellaneous

recommended

to the

appropriate

review

Staff

the letters

or supporting

staff

input

application,

clearance

are

For

be application

Therapist

Comment, — the

issues not

lengthy

reviewed

Staff

into

appjications

placed

materials

action

received

good

that

notations

documents

documents.

the reports

the

opens,

license.

or legal

licensing license

standffig,

fee

creates

and

ensuring

the

received,

the

and/or

online.

documents.

the

of$100,00

that date

Board’s

received

Board’s

Recommeñdadon:

through

the

Before

amiscellaneous

Board

are

system. require

stamps,

all

etc).

Applications

applicant’s

applications

incorrect,

documents

Legal

meeting

evaluating

the

in When

Staff

Board Staff

possibly

established the

an4

licensing

Counsel

complete,

matches

office

staff

file.through

agenda. disuibutes downloads

with

may

mafl

are

review,

the

creates

received,

system,

for

disciplinary/legal

application,

prior

require

number

for

Professional

supporting

When review.

staff

pmcessing

staff

mail.

supporting

and

the

and

staff

forwards in

the

compjete

mails prepares

Counsti

licensing

the

prepares

staff

Paper

application application.

documents licensing

complete

Health

must

issues

doemnents

applications

letter,

and

application

applications

may

the

and

system.

correct.

find

Monitoring

will

application

request system is

additional scans

Staff

ready

with

addition

and

require

(exam

Staff with for

then

pull

any

the the and

the

are

a Transaction Board Mminisftaffve Board Board Staff Fee-Related overhead. Medicine The Fee

Fee The Estimated Athletic Fee Phone Agency:.. Contact: fee fee Description: fime-roeess Objective: Title, Member Attorney Administrator No. slrnuld will Trainer to yearly fre process Rate be Overhead: Activities reQlew (1) K. Bureau 783-7194 review State charged Application: revenue: application Kaldpji offet and an review - BPOA of application to Estimated the Professional Johnson, every and identifiable

FEE $8,000 applicant Costs: and Acting

REPORT Collections: & (2) . costs . Occupational fbr defray Commissioner Total (.2Shr) (.2Thr) (.251w) (.251r) an incurred Athletic a Estimated portion

FORM Proposed by Aairs Trainer the of (80 Date: Cost: Fec: State the applicaUons Board’s license. July22, Board administrative of 2019 x Osteopathic . $98.54 $100.00 $14.00 $2.40 $26.00 $26.88 $16.96 $100.00) $12.30 Si 00.00 •

Program. application be for rearch

application disciplinary/legal staff to makes reviews respective any

documents files manually scores, Board

It Analysis,

is issued, evaluating

Athletic scanning..

miscellaneous

recommended

to the

appropriate

review Staff

the letters,

supporting

staff

input

application,

clearance

are

to For

application Trainer

Comment, —

the

not

issues

lengthy

reviewed

Staff into

applications

placed.

materials

action

received

good

notations that

docuiients

license.

documents.

the refls

thelicense

opens,

legal or’creates

licensing

standing, by.the

ieof$lOO.OO

and

ensuring

thc

received,

the

and/or

online.

documents.

in that.

date

Board’s

received

Board’s

Recommendation:

through the

Befére

Board

are require system.

miscellaijeous

stamps,

all

Applications

etc).

applicant’s

applications

incorrect,

documents

Legal

meeting

evaluating

the

in When

Staff

Board.

Staff

possibly

the

established

and

licensing

Counsel

complete, match

office

staff file

downloads

disth’butes”mail. agenda.

with

may

mail

are

review,

through

the

creates received,

system,

for

disdphrmty)legal

applicaff prior

require

number

for

Professional supporting

When review.

staff,nvards

processing

staff

supporting

and

the

and

staff

on,

in the complete

mails prepares

licensing

Counsel

the

prepares

slaff

Paper

application

application.

documents

licensing

complete

Health

must

issues

documents

applications

letter.

and

application

may applicatibns

the

and

system.

cdrrect.

find

Monitoring

will

application

is systeni request

scans

additional Staff

ready

with

addition

and

require

(exam

Staff

for with

then

pull

any

the and

the

are

to _ ___

S —

FEE REPORT FORM

Agency: State - BPOA Date: July22, 2019

Contact: K Kalonji Johnson, Acting Commissioner Bureauof Professional& OccupationalAffairs

Phone No. 783-7194

Fee Title,Rate and Estimated Collections: ApplicationIbr Perfisionist licetse: $120.00 Estimated yearlyrevenue: $1200 (10 applicationsx $120.00)

Fee Description: The fee will be chaigedto each applicantas a Perfiisionist.;

Fee Objective: . The fee should(1) ofThetth identifiable costsincurredby the State Boardofosteopathic Medicine to reviewandprocess an applicationas a Perfi]sionistand (2) defraya pothon of the Board’sadministrativeoverhead. .

Fec-RelatedActMties and-Costs: . - Staff time - processapplication (.75hr) . $36.90

Board Administratorreview (.251w). $16.96

Bord Attomeyreview (.25hr) . $26.88 Board Memberreview - (.251w) $26.00 Transactionfee $2.82

AdministrativeOverhead . $6.00 Total EstimatedCost $115.56

• ProposedFee: • $120.00

L_ - - I. I.

Analysis; Comtent, and Recommendation: It is recommthidedthat a feeof $120.00be eitablishedto evaluatethe applicationas a Perfiisjonist

Board StaThReviewsipplicaffonfor completeness,verifiesthat supportingdocuments areattached,contactscandidateto request anymissinginformation. Issues approval throughcomputhror prepareslefterof revfion. FEE REPORTFORM

Agency: State - BPOA Date: July 22, 2019

Contact: K. KBlonjiJohnson, Acting Commissioner Bureauof Professional & OccupationalAffairs

PhoñeNo. 783-7194

Fee Title, Rate and Estimated Collections: license Readllation Fee; Pcrlhsionist $105.00 Estimatedyearlyrevenue; S 1050 (10 applicadonsx $105.00)

Fee Description: The fee willbe chargedto each applicant whorequestsreactivafion of an expired license. This fee is thargedin addition to the.apopflate biennialrenewal fed.

Fee Objective: The ftc should(I) offsetthe identifuble costsincthred by theState Board of Osteopathic - Medicineto revi w and process an applicationfor reacffvaffonofan inactive licenseand

(2) defray apothoñ of the Board’s administrativeovcrhád. . -.

Fee-Related Activities and Costs:

• Board staff- pwceas applicatioh (SW) ‘.. . - $24.61 Board Admmmfrabr review $16.96

• Board Attorneyreview (.2Shr) $26.88 Board Memberteview (.25hr) $26.00 Transactionfee $2.51 AdministrativeOverhead $6.00 Total EstimatedCost: $102.96 Proposed Fee: $105.00 Regulations,

missing

information Staff teactivation biennial

Analysis, It

Tecommended

receives

information,

renewal

and

issues

Comment,

application,

verifies

fee

inactive

that

registration

researches

period

fee

reviews

license.

and

for

$105.00

computer

non-practice

This

for Recommendation:

current

completeness,

and/or

cycle

established

charged

through

microfilm

ensure

contacts

computer. addition

compliance

process

files

applicant

retrieve

the

application

with

appmpriate

request

the

pertinent

Aét

for

any

and • • Temporary It Analysis, Adthhilstrafive Board Transaction Board Board Staff Fee-Related Medicine The (2) Fee The license. Fee Application Estimated Fee Phone Agency: Contact: is defray recommeided fee fee Objectivç: Description: time Title, Attorney Administrator Member No. should will to - a yearly Graduate Comment, review fee portion review Rate Fee be Overhead: Activities review (1) 783-7194 Bureau K. review charged State for revenue: that Kalonji ofThet application and and of Pcthsiopist. a review - Temporary the BPOA a of procs to fee Estimated and the Professional Board’s Johnson, each and of$ identifiable

FEE $240 Recommendation: applicant an 120.00 Costs: Graduate administrative applithif Acting Proposed Total

REPORT Collections: & be costs Occupational applying established Estimated Pethisionist Commissioner on (.25hr) (.25hr) (.25hr) (.5hr) incurred Fee: for overhead. TemporuryGraduate for

FORM Cast: to Temporary by Affairs evaluate the Date: (2 State applications the Graduate July22, Board application Perfiisionist of Pethisionist 2019 Osteopathic x $1 $120.00 for $6.00 $120.00 $115.56 $2.82 $26.00 $26.88 $16.96 $24.61 20.G0) and rI..

BoardStaffi Reviewsapplicationkr completeness,veñües thatsupporlingdoQlments areattached,contactscandidateto requestanymissing infornmflon.Issuesapproval throughcomputerUt preparesletterofrejecifon. .Tmnsactionfee

Administrative

Board Board

Fee-RelatedActlvides Staff

Medicine nd Fee. The Paflisionist Fe The Estimated

Application Fee

Agency: Phone Contact

(2)

fee

time—review Objective: Description:

Tide,

Attorney

Administrator

No.

defray

wilibe should

yearly

review

Rate licenst.

for

Overhead

Bureau 783-7194 K.

(1)

State

review

charged 1

pottion

revenue:

Temporary

Kalonji

offset,

and

review

-BPOA

prncs

Estimated .

the

Professional

Johnson,

the each

and

identifiable

FEE Previsi

Board’s

$400 .

applicaht

Costs:

application

Acting

REPORT .

naLPerihsionist Collections;

& .

adminisnfivc

costs

Occupational .

applying

Commissioner

(.25k)

(.25hr)

(.5&)

incunedby

for

Temporary

for

FORM -

Total

Proposed

overhead.

license:

Temporary

Aflirs

Estimated

the

Date:

Fee;.

Provisional

State

applicafionsx

Provisional

July22, .

Board

Cost; .

Pcrfiisfonist

2019

Osteopathic .

S80.O0

$60.00) .

$76S1. $80.00 S6.0O

$1.86 $26.88. $1635

$24.61 - r -

Board through are Analysis, his Temporary

attached,

recommended

Staff;

computer

Provisional

Comment,

contacts

Reviews

that

prepares

candidate

application

a Pflsionist.

fee

and

leüer

Recommendation:

$80.00

thr

request

compleLeness,

rejection.

àtablishedto

any

thissli]g

v&ifles .

infotmafion.

evaluate

that

supportin

the

application

ssues -

approval

documents

ith FEE REPORT FORM

Agency: State - BPQA Date: July 22, 2019

Contact: K. KalonjiJohnson, Acting Commissioner Bureau ofpmfessional & OccupationalAffairs

Phone No. 7S3-7194

Fee Title, Rafe and Estimated Collections: Application for GeneticCounselor License: $120.00

Estimated yearlyRevenue: $1200 .. (10 applications x $120.00)

Fee Description: . The fee will be chargedto everyapplicant fQra Geneticounselor license.

Fee Objective:

The fee thould (I) offsetthe identifiable colts incurredby the state Board of Osteopathic Medicine to process an applicationand (2) defray a portionof the Board’s administrative overhead.

Fee-Related Activities and Costs: Staff time-processapplication (.75hr) $36.90 Board Mthinisthitor review (.251w) $16.96 Board Attorneyreview (.251w) $26.88 Board Memberreview (.251w) $26.00

Transaction fee . $2.82 AdministrativeOverhead $6.00’ Total EstimatedCost; $115.56 Proposed Fee: $120.00 • 8

Analysis, Comment, and Recommendation: It is recommendedthata fee of $120.00be establishedforprocessingan applicationfora Genetic Counselorlicense.

Application for Genetic Counselor License

Board Staff - receives application,reviews for completeness,vcrifies thai supporting documents are attached, con acts applicant to request any missing information an&or documents. lnfonnation provided on the application regarding criminal conviction/chemicaldependency/etc.may necessitatefurtherresearch and review. Tfrnc to cover ziew and action by legal office has been averaged over total number of applicationsanticipatedin a biennial cycle. Board staff issues licaise through computer when applicationis complete. r

Administrative Transaction

Board Board Board

Staff Fee-Related The overhead. Medicine The

Fee

Application Estimated Fee Agency: Fee Phone Contact

fee

time-process

Objective:

Description: Title,

Member

Attorney

Administrator

No.

should

will

yearly

fee

process

be fbr

Rate

783-7194 Bureau K. Overhead

State. review (1)

charged

review

Reactivation

Activities

revenue:

Kalonji

application

offset

an and -

review

BPOA

application

the

Professional

Johnson,

Estimated every

identifiable

FEE

and

applicant

Genetic

and

Acting

$525

Costs:

REPORT

Proposed

Total

(2)

costs

Occupational

Collections:

Counselor

for

Estimated

defray

Commissioner

(.25hr) (.25hr) (.25hr)

incuted

Fee:

Genetic

portion

FORM

License:

Cost:

Affairs

Counselor

the

of,the

Date:

applications

State

Scald’s

July

licaise.

Board

22,2019

S2.51

$26.00 $26.88 $6.00 administrative $105.00 $102.96 $24.61 S of

16.96

$105.00)

Osteopathic

05.00 documents. to application It applications when documents Board Analysis, convictio&chemic&

cover

recommended

application

Staff

review

for are

anticipated -

Comment,

receives

attached,

Genetic

Information

and

that

complete.

dependencyfete.

action

in appliqafion,

fee

Counselor

contacts

and

of$

biennial

wovided

105.00

legal

Recommendation:

applicant

license.

reviews

may

cycle.

office

necessitate

established•forpwcessing

Board

for

has

request

the

completeness,

been

staff

further

application

any

issues

averaged

missing

research

license

verifies

over

regarding

information

and

reactivation

through

total

that

review.

number

supporting

computer

crimina!

andior

Time

of I

Administrative Trunsactioh Board Board

overlead.

StAff Medicine The

Fee-Related The license. Fee Fee Application Agency: Estimated Fee PhuneNo. Contact:

fee

fewi1lbe

time-process

Title, Objective: Description:

Administrator Attorney

should

yearly

fee•

for process

Rate

Bureau 783-7194 State K.

Overhead

(1)

charged

Temporary

review

Activities

Revenue:

Kàlonji

application

otThet

and

-BPOA an

review

application

the

Professional

Johnson,

every

Estimated

Provisional

identifiable

FEE

and .

applicant

and

Acting

$1350

REPORT

Costs:

Proposed

Tdtal

Genetic

(2) -

casts Occupational

Collections:

for

Estimated

Commissioner

defray

(.25hr) (.25hr) (.75hr)

incurred

Fee:

Temporary

Counselor

FORM

portion

Cost:

Affairs

the

License:

Provisional

Date:

(15

State

the

applications

Board’s

July

Board

Genetic

22,

$90.00

$88.91 $2.17 $26.88 $6.00 $16.96 $36.90

4dminisfradvc

2019

Osteopathic

$90.00)

Counselor

$90.00 Application when documents Board documents. to conviction/chemical applications It Analysis, Temporary

cover

recommended

application

Staff

review

Provisional are

anticipated -

Comment,

receives

attached,

for

Information

and

that

complete.

dependency/etc.

Genetic

action

Genetic

application,

fee

contacts

and

biennial

$90.00

provided

Counselor

legal

Recommendation:

applicant

reviews

may

cycle.

office

established

necessitate

license.

Board

for

has

License

request

the

completeness,

been

staff

for

further

application

any

issues

averaged

processing

missing

research

license

verifies

over

regarding

information

and

through

application

total

that

review.

number

supporting

computer

criminal

and/or

for

Time

of CDL-1

FACE SHEET FOR FILINGDOCUMENTS WLEtOU U WITH THE LEGISLATIVEREFERENCE BUREAU JUN152020 (Pursuant to Commonwealth Documents Law) Independent Regulatory ReviewCommission

DONOTWRrrE INThis SPACE Copy belowIshereby approved as to - Copybeow is here by cenifledInbe a Iwé and totted py Copybelow is hereb, apüràved as to form formand Ie9alfty.AttorneyGeneral of a documentIssued. prescribed or promulgatedby: and legality. Executiveor Independent Agencies.

BY: BY: - Mkt

—-

- DOCUMENT/FISCALNOTENO. 16A-5334

DATEOFADOPTION: ...AngtQlQZQ..__.___. 6 / 10 / 20 2 0 DATEOF ?PROVAL tA. A )flJ7,4 PATh OFAPPROVAL Aôakc,IJ ‘V Deputy General Counsel BY: ‘L_LL..._...______(GNeSounseblndcpendent-Agency) Randy 0. Litman, D.C. Strie inapplicabe tine)

C Check Ifapplicable I Q Check IIapplicable. NoAhomey General Copy notapproved. Objections TITLE Bbard Chair ObJedOi M hin00 days alit, [_aeached — — (EXECUTh’EOFFICER CHAIRMANOR SECRETARY)

FINAL RULEMAKING -

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF STATE - BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS STATE BOARD OF OSTEOPATHIC MEDICINE TITLE 49 PA CODE, CHAPTER 25

49 Pa. Code § 25.231 and 25.503 FEES 16A-5334- Fees Final Preamble June 3. 2020

The State Board of Osteopathic Medicine (Board) hereby amends §25.231 (relating to schedule of fees) and deletes §25.503 (relating to fees) to read as set forth in Annex A.

Efkctive Date

This rulemaking will be effective upon publication in the Pe,msi’/iinia flu/kiln. The initial increase for application fees will be implemented immediately upon publication. Thereafter, the subsequent graduated increases for application fees will be implemented on a 2- Fiscalyear (FY) basis on Jttly 1.2022, and July 1,2024.

The increased biennial renewal fees will be implemented beginning with the November 1, 2020—October 31, 2022, biennial renewal period for osteopathic physicians, physician assistants and acupuncturists. Thereafter, the subsequent graduated increases for osteopathic physicians, physician assistants and acupuncturists will be implemented with the biennial renewal for November 1, 2022—October 31, 2024, and for November I, 2024—October 31, 2026.

For respiratory therapists, athletic trainers, perfusionists and genetic counselors, the increased biennial renewal fees will be implemented beginning with the January 1, 2021— December 31, 2022, biennial renewal. Thereafter, the subsequent graduated increases for respiratory therapists, athletic trainers, perfusionists and genetic counselors will be implemented with the biennial renewal for January 1, 2023—December 31, 2024, and for January 1, 2025— December 3!, 2026.

Statiruny Au/horfli’

Under section 16 of the Osteopathic Medical Practice Act (act) (63 P.S. § 271.16), the Board has the “power to adopt and revise such regulations as are reasonably necessary to carry out the purposes of this act in conformity with the provisions of the act of July 31, 1968 (FL. 769. No. 240). known as the “Commonwealth Documents Law.” Section 13.1(a) of the act provides that “[i the revenues raised by fees, Finesand civil penalties imposed under this act are not sufficient to meet expenditures over a two-year period, the board shall increase those fees by regulation so that the projected revenues will meet or exceed projected expenditures.” Under the act, all “fees, fines and penalties imposed ... shall be for the exclusive use by the board in carrying out the provisions of this act and shall be annually appropriated for that purpose.” 63 P.S. § 271.13a(c). Thus, unlike most other professional licensure boards that fall under the

Professional Licensure Augmentation Account (PLAA) (see 63 P.S. § 1401-301), the Board is fiscally independent.

Backgiainid mu! Pit;po.ce

This final rulemaking increases application fees to reflect updated costs of processing 16A-5334- Fees Final Preamble June 3,2020 applications and increases all the Boards biennial renewal fees to ensure its revenue meets or exceeds the Board’s current and projected expenses. This rulemaking increases the following application fees on a graduated basis: osteopathic physicians, short-term camp osteopathic physicians, temporary training licenses or graduate training certificates, physician assistants, supervising osteopathic physicians, acupuncturists and physician acupuncturist, respiratory therapists. athletic trainers, perfusionists, reactivation of perfusionist licenses, temporary graduate perlbsionist licenses, temporary provisional peribsionist licenses, genetic counselors, genetic counselor reactivations and temporary provisional genetic counselors. Approximately 2,600 applicants will be impacted annually by the increased application fees.

The Board is also implementing graduated biennial renewal fee increases for the following licenses, certificates and registrations: osteopathic physicians., physician assistants, acupuncturists, respiratory therapists, athletic trainers, perftisionists and genetic cotinselors. There are approximately 12,700 individuals who, possess current licenses, certificates and registrations issued by the Board who will be required to pay more to renew their licenses, certifications or registrations.

Under section 13.1(a) of the act, the Board is required to support its operations from the revenue it generates from fees, fines and civil penalties. The act further provides that the Board shall increase fees when expenditures outpace revenue. The majority of general operating expenses of the Board are borne by the licensee iollulation through revenue generated by the biennial renewal of licenses. A small percentage of its revenue comes from application Fees, fines and civil penalties. The Board receives an annual report from the Department of State’s Bureau of Finance and Operations (BFO) regarding the Board’s income and expenses.

In consideration of the comments rcccivcd regarding the amount of increase For osteopatluc physician fees in addition to thc fiscal impact of COVID—19, the Board asked BFO to review the Board’s current Iiscal status and provide an tipdated linancial report. BFO found that, in addition to some increases in revenue and licensee count since 2019. the expenses incurred by the Board during the pandemic have decreased. Dtiring FY 2016-2017 through FY 2017-2018, the Board received biennial revenue of 52,128,270.14, incurred expenses of 53.221,243.36 and ended with a remaining balance ofSI,712,593.53. For FY 2018-2019 through FY 2019-2020, the Board projects receiving biennial revenue of S2,233,122.60 and projects incurring expenses of S3,545,l85.74. At the end of FY 2019-2020, BFO projects a remaining balance of 8400.53039, which is only enough to cover approximately 3 months of expenditures. For FY 2020-2021 through FY 202 1-2022, without an increase in fees, the Board projects revenue of 52.339 million and projects expenses of 53.804 million, with a deficit balance in FY 2021-2022 of (51,064,469.61). Thus, the updated BFO data demonstrates that the Board’s revenue, even with the increases in revenue and decreased expenditures, is still not sufficient to meet or exceed its expenditures over a 2-year period. l6A-5334- Fees Final Preamble June 3, 2020

While fee increases are still needed prior to the next renewal period lhr the Board to remain solvent, the Board was able to decrease biennial renewal fees lbr physicians. as compared to the proposed fee schedule. to ease the burden. As reflected in Annex A. the biennial renewal fees for osteopathic physicians were adjusted down from $350 to $330 in the November 1, 2020—October 31. 2022, biennial renewal period; From $425 to $420 in the November 1, 2022—October 31. 2024, biennial renewal period; and from $475 to $450 in the November 1, 2024—October 31. 2026. biennial renewal period.

The new fee structure is projected to produce biennial revenues o1 53.949 million in FY 2020-2021 through FY 2021-2022, which will allow the Board to meet or exceed its projected expenditures of 53.804 million; $4938 million in FY 2022-2023 through FY 2023-2024, which will allow the Board to meet or exceed its projected expenditures of $3.9IS million; and 55.314 million in FY 2024-2025 through FY 2025-2026, which will allow the Board to meet or exceed its projected expenditures of 54.036 million; and will then put the Board back on firm financial ground.

Sie,,,man’and Re.vpoirvesto Co;nnwnts

Notice of the proposed rulemaking was published at 50 PuB. 1364 (March 7, 2020). Publication was followed by a 30-day public comment period during which the Board received 36 public comments. Thirty-three of the public comments were from physicians. The Board also received a comment from the Pennsylvania Osteopathic Medicine Association (PUMA) and the Pennsylvania Medical Society (fAMED). In addition, the House Professional Licensure Committee (HPLC) submitted comments and the Independent Regulatory Review Commission (IRRC) submitted comments. The Senate Consumer Protection and Professional Licensure Committee (SCP/PLC) did not submit comments.

General Support/br the Fc’c’Increase

In the comment submitted by POMA, it recognized and “supports the need for the State Board of Osteopathic Medicine (Board) to raise its fees via regulation 16A-5334 to meet its operating expenses.’ Likewise, PAMED does not oppose the fee increase, but rather is concerned that there would be insuFficient time to implement the Feeincreases beginning with the November 1, 2020—October 31, 2022. biennial renewal period for osteopathic physicians, physician assistants and acupuncturists. POMA also expressed some concern regarding the timing of the regulation given the upcoming the November 1.2020—October 31, 2022. biennial renewal period. PUMA questioned whether there would be sufficient time to promulgate the regulations before the renewal, especially given COVID-19 pandemic. Both issues are more folly discussed below. 16A-5334- Fees Final Preamble June 3, 2020

General Opposif ion to the Fee Increase

The Board received 16 comments Fromphysicians expressing general opposition to the fee increases. These commenters opposed the increase in fees either because the fees were too high or were unnecessary. Two commenters opined that the physician fee increases were not in line with inliation and live commenters raised concerns about whether certain physicians could afford the increase, including part—timeworkers, practitioners who have practices in more than one state, and partially retired physicians who help with physician shortages. One commenter opposed the increased fees because of his concern about physician shortages in primary care and another said that the Board should not charge significantly more in biennial fees as compared to medical doctors. One commenter suggested monthly withdrawal options. Additionally, in POMA’s comment, it noted that it received some general concerns with the size of the increase, but it “fell short ofopposition.”

As previously indicated. BFO updated its data to ensure that the Board was appropriately considering the current fiscal picture. especially given the COVID-19 pandemic. Even with some increased revenue and decreased expenditures, the Board will not be able to meet its expenditures over a 2-year period in FY 2019-2020 and thereafter. Therefore, in addition to increased application fees, an increase in biennial renewal fees beginning in FY 2020-2021 is necessary, as set Forthin Annex A. In adopting the increased fee schedules, the Board carefully reviewed the data presented by BFO and balanced the need to remain fiscally solvent against the negative fiscal impact to licensees. With the decreased biennial renewal fees for physicians. the increases for each renewal period are projected to produce biennial revenues of: $3949 million in FY 2020-2021 through FY 2021-2022, which will allow the Board to meet or exceed its projected expenditures of $3804 million; S4.938 million in FY 2022-2023 through FY 2023- 2024, which will allow the Board to meet or exceed its projected expenditures of $3918 million; and $5.3 14 million in FY 2024-2025 through FY 2025-2026, which will allow the Board to meet or exceed its projected expenditures of $4036 million; and will return the Board to a fiscally sound position.

In response to the concern that the ph>sician fee increases are not in line with inflation. the Board agrees that it did not calculate the (Ce increases based on inflation. For application Fees.the initial increase is designed to cover the cost to process applications. This fee is borne by individual applicants. Actual cost calculations for application ICesare based upon the Folloing formula:

number oFminutes to perform the Function

pa> rate fOrthe classification of the personnel

per him ing the Fitnction + l6A-5334- Fees Final Preamble June 3.2020

a proportionate share ofadministrative overhead Application fees for FY 2020-2021 are based on time study reports created within the Bureau of Professional and Occupational Affairs (Bureau) giving each step in the process and the amount of time it takes to process one application. That amount is multiplied by the anticipated application reqtiests for one s-ear(multiplied by two since the increases are biennial). Increases which “ill be effective July I, 2022. and July I. 2024. are calctilated at a 9.5% increase as pay increases Forstall that process applications are 2.5% in July and 2.25% in January or 4.75% annually (9.5 biennially) and the fee is almost entirely dependent upon personnel—relatedcosts. For osteopathic physicians, the current 545 application fee has been in place since January 29, 2000. Raising the application fees for physicians to SI 70 reflects increases in the cost of processing applications since January of 2000. This fee increase is appropriate so that the applicants, and not existing licensees, fully bear the cost of processing those applications. With regard to the increase in biennial renewal ICes, the Board does not rely on inflation rates to determ ic these ICes. Instead, the Board must consider the amount of revenue required to meet or exceed the Board’s expenditures which includes Board administration, Commissioner’s and Revenue ollice services, Departmental services, legal office services, hearing expenses, enforcement and investigation costs, Professional Compliance Office costs, board member expenses and Professional Health Monitoring Program (P1-IMP)costs. The majority of the Board’s costs are personnel related, and much of those costs are not within the Board’s control. Staff are generally employees of the Commonwealth, most of whom are civil sen-ice personnel, and many are union positions. For these employees, the Board is bound by the negotiated contract. Personnel costs associated with investigation and enforcement depend largely on the number of complaints received that need to be investigated, and the number of those matters that result in disciplinary action. The Board has no control over the number of complaints that are filed against licensees and unlicensed individuals, nor may they control which matters are or are not prosecuted.

Over the last few fiscal years. the Board has had some sizable increases to expenses for a variety of reasons. One of the largest financial impacts for the Board was the incorporation of The Pennsylvania Justice Network (JNET), due in pan to the enactment of act of February 15, 2018 (P.L. 14, No. 6) (Act 6 of 2018), which reqtnres mandatory self-reporting of criminal convictions. The Board uses JNET to identify criminal convictions of licensees and to verify compliance with Act 6 of 2018’s mandatory’reporting requirement. Initially, the Board was one of three (3) boards under the Bureau that incorporated JNET criminal notifications into their business processes. Across the three (3) boards, there was a sizable 27.5°z average increase in the number of complaints being processed and opened for prosecution. With the additional complaints, increased expenses due to higher prosecutions, investigations, expert witness usage, and hearings resulted. Since incorporation of JNET, expenses have been relatively steady in all of these cost categories. More than likely, this new level of legal workload is one that will be part of the financial picwre for the Board going fonvard. 16A-5334- Fees Final Preamble June 3,2020

In addition to the legal increases, all 29 boards and commissions tinder the Bureau have undergone an information technology transformation upgrade with the incorporation of the Pennsylvania Licensure System (PALS). Expenses associated with PALS, including the initial build as well as ongoing maintenance, are proportionately spread across all entities based on licensee population as a way to effectively share costs per licensee. While the initial build is in the past, it has contributed to higher administrative expenses for all boards during the last few fiscal years. Due to PALS’ high Functioning database with enhanced features over the Departmen(s previous License 2000 platform, maintenance For this system requires a larger financial commitment from all boards and commissions than the previous system.

In response to those commenters who oppose fee increases with regard to part-time practitioners, practitioners who have practices in more than one state, or partially retired physicians who help with physician shortages, the Board cannot distinguish between licensees based on the number of hours they work, as the Board has no control over that number. The Board also cannot distinguish between licensees based on their annual income. Kistoricall. the Board has taken steps to ensure that thc financial burden placed on licensees is commensurate s ith the Board’s obligations and expenditures. For example. in March of 2010. the Board reassessed the impact oF the mandates tinder the Medical Care Availability and Reduction of Error Act (MCARE Act) (40 P.S. § 1303.101—1303.910) and decreased the biennial renewal Feefor osteopathic physicians fioni $440 to the current Feeof’$220. Consistent with its continued commitment to minimize fiscal impact to its licensetm.the Board has re—reviewedits fiscal needs and the changed fiscal circumstances given COVID-19 and has decreased the proposed biennial fees for physicians to provide some relief. Additionally, the Board’s graduated fee increases, as opposed to a one-time flat fee increase, minimize the initial impact of the increases.

In response to the comment that the Board shotiId not charge significantly more that the State Board of Medicine (Medical Board) charges its physicians, the Board’s initial increase iii biennial Fees is $330 whereas the biennial renexal fee (‘ormedical doctors is $360—$30 more than the Feebeing proposed Forosteopathic physicians in the November I. 2020—October 31. 2022. rene al period. Regarding the comment suggesting monthly withdra al payments. the Bureau is not ctirrently able to Facilitatethat type of aLitomaticpament plan.

Another commenter suggested that the Board obtain revenue from another source- The Board is required by the act to support its operations from fees, fines and civil penalties. Because the Fees, fines and penalties imposed under the act are for the exclusive use by the Board in carrying out its duties and obligations in the act, the Board maintains a separate account, independent from the PLAA. As such, the Board’s Funds collected in accordance with the act are specifically allotted to the Board in a separate account and the Board determines its fees based upon the revenue it receives and the Board’s expenditures. Additionally, section 13.1(a) of the act provides that ‘[i]f the revenues raised by fees, fines and civil penalties imposed under this act are not sufficient to meet expenditures over a two-year period, the board shall increase those fees by regulation so that the projected revenues will meet or exceed projected expenditures.’ Thus, receiving funds from other sources does not appear to be a viable option. 16A-5334- Fees Final Preamble June 3. 2020

While the Board is empathetic to all of the concerns put forth by commenters, the Board is dutybound to ensure that the Board remains fiscally sound so that is may carry out the mandates of the General Assembly set forth in the act in furtherance of the public health and safety. Without a fee increase. BFO anticipates that by the end of FY 2021-2022 the Board will be in a deficit, and thus, increasing fees is critical to sustain the operations of the Board. The Board is statutorily obligated to increase fees by regulation when revenues raised by fees, fines and civil penalties under the act are insufficient to meet expenditures over a 2-year period. The Board meets this criterion, and thus, is required to increase its fees.

Inv,if/ic’ienr Tinic to Resjont/ ciiul C()l)?IiiCi,t,[ hici,fi,cwi,t hi i ‘oh’e,ne,,t of the Regulated Conununm’

The Board received comments from three physicians asserting there is insufficient time for debate and vetting. Other commenters said there was a lack of notification and involvement with the regulated community. IRRC also commented that extraordinary pressures and work burden have been placed on medical professionals during the pandemic which necessitate additional time for the regulated community to review and comment on the proposal.

In August of 2016, the Board began discussing at its public board meetings an increase in biennial renewal fees. The proposed rulemaking was disctissed at public board meetings on August 10, 2016, August 9,2017, February 14, 2018, April 11,2018, August 22, 2018, October 24, 2018, February 13, 2019, August 14, 2019, and December 11, 2019. Beginning in approximately 2016, the Bureau and the Board reviewed its application fees and deterniined that the existing fee schedule did not reflect the costs of the services provided by the Board. Based upon tIns determination, the Board and the Bureau evaluated the cost of processing the Board’s applications, and a new fee schedule was recommended to the Board. On May 8,201$, the Board released an exposure draft to stakeholders and interested parties that included the increased application fees as well as increased biennial renewal fees After receiving minimal responses from the exposure draft, the Board moved lbrward with drafting the regulaton’ package. In 2019, the Board revisited the structure of its fee schedules and voted to adopt a graduated fee schedule to minimize the initial impact of increased fees on licensees and to ensure that the Boards fees are commensurate with its obligations and expenditures. The proposed regulation was considered by the Board and drafted well in advance of the COVID-19 crisis and was published as proposed on March 7. 2020, before COVID-l9 began to have substantial impact in Pennsylvania.

While the Board recognizes the impact of COVID-19 on its regulated community, given the timeline outlined above, the Board believes there has been sufficient time for physicians to react and respond. Additionally, the association that represents the majority of osteopathic physicians in the Commonwealth (POMA) regularly attends tIle Board meetings, was aware of the proposed fee increases and does not oppose the increases. While the Board understands that the COVID-l9 pandemic has placed an additional burden on many physicians across the IbA-5334- Fees Final Preamble June 3, 2020

Commonwealth. there has been sufficient opportunity to provide input into this rulemaking. Moreover, the Board has very little room for debate with regard to the Feesit charges, given that application lees are based upon actual costs to process applications and increases in biennial renewal fees are based upon fhnds required to meet the Boards statutory obligntion to produce sufficient revenue to meet expenditures over a 2-year period.

Inipk’ineiitatioiiDate o[the Final Rzileniaking

POMA, PAMED and IRRC all submitted comments regarding the timing of the regulations and questioned whether there is sufficient time to promulgate regulations in time for the renewal notices that are generally sent out approximately 60 days prior to the expiration of the biennial perio& POMA and PAMED asked if the Board had a contingency plan in case the regulation is not promulgated in sufficient time to proceed with the November 1.2020—October 31, 2022, biennial renewal period. POMA and FAMED also asked detailed questions regarding the possibility-of extending the biennial renewal deadline.

While the Board acknowledges that the turnaround time between the proposed rulemaking and the final rulemaking is ambitious, the Board remains committed to do the work necessary to promulgate the regulations within sufficient time to process renewal notices Forthe November I, 2020—October 3!, 2022. biennial renewal period. Regarding the question as to whether the Board has a contingency plan, absent unforeseen circumstances, the Board believes it has sufficient time to promulgate this regulation. The Board understands that COV!D-l9 makes the normal regulatory process uncertain. Procedures have been put in place by IRRC, the Legislative Reference Btireati. HPLC, SCPJPLC, and the Office of Attorney General to efThctuateelectronic delivery of regulations. If, however, the Board is unable to present this regulation at the scheduled July 16, 2020 IRRC meeting, the Board may have to consider other options such as extending the biennial period. Other Boards, in conjunction with the Governor’s office, have effectuated this extension because of the impact of COVID-19. Regarding questions relating to procedures and parameters that an extension might involve; the Board does not know whether an extension is necessary nor does it know how it might implement the terms of an extension. Those types of questions would be addressed within the context of requesting authorization and receiving approval to extend the expiration of the biennial period.

FinaLly,FAMED asked if there is a date by which the Board must have the regulations approved for the fee increase to go into effect. The Board has historically sent out renewal notices approximately 60 days prior to the date of the expiration of licenses. The Boards plan is to send out renewal notices by the beginning of September. Assuming both IRRC and the Office of Attorney General approve the rulemaking, the Board believes it will be able to promulgate the regulation in time to send the renewal notices out within the 60-day period. IÔA-5334-Fees Final Preamble June 3. 2020

Fec’sShould ‘vot be Increased During the Co VID—19 Pandemic

The Board received 14 public comments opposing the increase fees because of the COVID—19pandemic. Commenters suggest to the Board that fees should not be raised during the pandemic. Some commenters opined that raising fees for physicians would cause financial hardship, in part, because physicians have suffered a negative financial impact due to the pandemic because of cancelled appointments, cancelled elective surgeries and laying off staff. PAMED and one commenter asked if the Board was prepared to delay or cancel the fee increase. IRRC also commented and expressed concern that the fee increases will cause financial harm during the pandemic and asked the Board to withdraw the rulemaking and resubmit it at a later date. Similarly, the HPLC submitted a comment recommending that the fee increases contained in the proposed regulation be delayed until after the end of the COVID-19 emergency.

WIule the Board understands the impact the pandemic has had on its licensees, including the negative financial impact that has occurred to the regulated community, the Board’s work in proposing the fee increase began long before the pandemic. The Board is statutorily mandated to increase fees by regulation if the projected revenues will not meet or exceed projected expenditures. Delaying the collection of fees is not fiscally feasible because the Board expects to have a balance of S400,530.39 at the end of FY 20 19-2020 (June 30, 2020), an amount that would only be expected to cover one quarter of expenses. In addition, with the fee increases, the Board projects that it will be in a deficit situation by the end of FY 2020-2021 At that point, with no other revenue sources available to the Board, the Board would likely have to cease operations.

The Board Should Merge with the State Board o/ Medjenie to Dec,ea.ce uldn,i,ustmtii’e and Overhead Costs

Nine commenters suggested combining the Board with the Medical Board to decrease administrative and overhead costs. Both the Board and the State Board of Medicine were statutorily enacted through the act and the Medical Practice Act of 1985 (63 P.S. § 422.1- 422.53). Neither the Board nor the Medical Board are empowered to combine the Boards; combining the respective boards is not an option without legislative action.

Questions Regarding Expenditures

Several commenters questioned the Board’s oversight of its expenses and requested more information regarding the Board’s expenses. POMA and one other commenter asked how the Board spent its revenue. Another commenter did not understand why the Board required an increase given the lack of sen’ices provided by the Board.

At least annually, the Board reviews and receives a report from BFO regarding the Board’s fiscal status, income, and expenses. These reports are done in public session and placed in the Board’s minutes. Members of the public are welcome to review this information or attend Board meetings. As indicated above, in aadition to expected increases in personnel costs, the Board has had some sizable increases to expenses, including the implementation of JNET notifications which caused a 27.5% average increase in the number of complaints across the three boards (including the Board) that implemented the JNET notifications, and technology upgrades and maintenance of the new database. The fee increases for application and biennial renewal fees will enable the Board to continue to create a small surplus in funds in their restricted account should there be any additional unknown financial impacts.

Another commenter asked if the Medical Board has the same fiscal issues as the Board. The Board and the Medical Board are separate entities and have different expenditures. The Medical Board is not experiencing the same fiscal issues as the Board and is not in need of a fee increase; however, as previously stated, in March of 2010. the l3oard reassessed the impact of the mandates under MCAR[3Act and decreased the biennial renewal lee (or osteopathic ph sicians fb $410 to the current Feeof $220. So. Forthe last 10 years the renewal ICefor osteopathic physicians has been $220 whereas the ICeFormedical doctors has been 5360—S141)less than the Medical 3oards biennial renewal ICe. The Board took the step to decrease fees in 2010 to minimize the liscal impact to its licensees and until this rulemaking. osteopathic ph sician renenal fees ere significantly less than the Medical [3oard. Even ith this fee increase, the biennial fee increase will still he less than the Medical Board for the November 1, 2020— October 31, 2022, biennial renewal period. While the subsequent fee increases will raise the fee above the current Medical Board fee, this is not unexpected given the 10 years Board licensees have enjoyed the lesser fee as compared to the Medical Board. Moreover, of the surrounding states that have separate osteopathic licensing boards (Maine, Vermont and West Virginia), the Board’s graduated fee increase is less than or comparable to fees charged in those states—Maine ($500). Vermont ($350) and West Virginia ($400).

PAMED asked whether the Board would consider decreasing the biennial renewal fees for the November 1, 2022—October 31, 2023, and the November 1, 2024—October 31, 2026, biennial renewal periods if the fee increases produce sufficient revenue to meet or exceed its expenditures. As previously stated, the Board is statutorily obligated to increase fees by regulation when revenues raised by fees, fines and civil penalties under the act are insufficient to meet expenditures over a two-year period. The purpose of the fee increase is to bring the Board in compliance with the act by producing sufficient revenue to meet or exceed its expenditures 16A-5334- Fees Final Preamble June 3, 2020 over a 2-year period. The Board does not anticipate decreasing the biennial fees for the November 1, 2022—October 31, 2024, and the November 1. 2024—October 31, 2026. biennial cycles because the Board has projected that it is in need of the increases to comply with the requirements of the act and to place the Board on solid financial ground. Having said that, as the Board did in 2010, if the Board finds that the revenue collected fhr outpaces its expenditures, the Board will consider decreasing its fees in the future. The Board has historically taken steps to rigorously evaluate its Fiscalstatus and will continue to do so to ensure that licensees only incur fees that are fiscally necessary.

RRC asked for more detailed financial information, including fiscal documentation that would show that projected revenues meet or exceed projected expenses over a two-year period. The Board generally attaches to its proposed rulemaking a copy of BFO’s financial report detailing the Board’s financial status and Feereport forms that provide a breakdown of costs for application fees. The Board inadvertently did not attach those documents to the proposed rulemaking. The Board apologizes for this oversight and has attached the fiscal documents to IRRC’s Regulatory Analysis Form in this final-form rulemaking. and will make the documents available to the public on request.

Other ConiiizenIs

Public comments were received that presented issues outside the scope of this rulemaking. While those comments have been reviewed, the Board will not provide substantive responses to those questions and comments. For example, one commenter asked the Board to consider changes in licensure requirements. Two other commenters complained about the time to process their licensure applications. Although the Board is not responding publicly to these concerns, the Board has responded to commenters who identified issues with the processing of their applications.

Comment Received a/Icr the Pith/ic Coi;inieiit Pt’i’iod

The Board received one of the 36 public comments after the 30-day public comment period which was from an osteopathic physician. This commenter raised similar concerns outlined above regarding the Board’s Feeincrease during COVID-l9. This commenter also stated that the “membership” and patients should not be held liable for the Board’s errors.

The Board’s fee increase is not due to any error by the Board. As outlined above, the Board is statutorily obligated to increase fees by regulation when revenues raised by fees, fines and civil penalties under the act are insufficient to meet expenditures over a 2-year period. The Board meets this criterion and, therefore, is obligated to increase fees. Also, the Board is a state governmental board that has powers and duties as outlined in the act. Licensees are not members and do not pay membership fees, but rather, pay fees to apply for and renew licenses to pursue and continue practice in osteopathic medicine. 16A-5334- Fees Final Preamble June 3,2020

Description of .-inicn(lfl?c’I?t.c(1) the Final—FormRtileinaki;;g

In response to comments received as well as changed fiscal circumstances, due in part to COVID-l9, the final-form rulemaking amends § 25.231 (relating to schedule of fees) to decrease the biennial renewal fees for osteopathic physicians from S350 to S330 in the November 1, 2020—October 31, 2022, biennial renewal period; from S425 to $420 in the November 1, 2022—October 31, 2024, biennial renewal period; and from $475 to $450 in the November 1, 2024—October 31, 2026, biennial renewal period.

Fiscal Impact and Papcntmi Requirements

The amendments will increase application and biennial renewal fees. All applicants, licensees, registrants and certificate holders will be required to comply with the regulation. The fees may be paid by applicants, licensees, registrants, or certificate holders or may be paid by their employers, should their employers choose to pay these fees. The final-form regulation should have no other fiscal impact on the private sector, the general public or political subdivisions of the Commonwealth.

Approximately 2,600 applicants will be impacted annually by the increased application fees. Specifically, the number of applicants affected are as follows: 1,200 osteopathic physicians; 600 temporary or graduate trainees; 60 short-term camp physicians; 500 physician assistants; 51 supen’ising physicians; 13 acupuncturists and physician acupuncturists; 10 perfusionists; 5 perfusionists seeking reactivation; I temporary graduate perftisionist; 3 temporary provisional perfusionist; 80 athletic trainers; 50 respiratory therapists; 10 genetic counselors; 5 genetic counselors seeking reactivation; and IS temporary provisional genetic counselors.

Based upon the graduated application fee increases, the total economic impact per fiscal year is as follows:

FY 20-21: $263,780 Fl 21-22: $263,780 FY 22-23: S32,275 FY 23-24: S32.275 FY 24-25: $43,806 FY 25-26: $43,806 Total: S679,722

There are approximately 12,721 individuals who possess current licenses, registrations and certificates issued by the Board who will be required to pay more to renew their licenses, ______,

I6A-5334- Fees Final Preamble June 3,2020 registrations and cenificates. Specifically, the number individuals affected are as follows: 9,009 osteopathic physicians. 2.603 physician assistants. 159 acupuncturists, 39 perfusionists, 326 athletic trainers. 560 respiratory therapists and 25 genetic counselors.

Based upon the above biennial renewal fee increases, the economic impact is as follows:

FY 20-21: S1,086,328 FY 22-23: S 923,345 FY 24-25: S 288,830 Total: 52,298,503

Thus, the total economic impact to applicants, licensees, registrants, certificate holders or employers, ii employers choose to pay application or licensing fees, is 52,977.218. This amount reflects the economic impact that will occur between FY 2020-2021 and F’ 2025-2026.

This rulemaking will require the Board to revise its printed and online application fonns. The amendments will not create additional papenvork for the regulated community or for the private sector.

Sunset Date

The Board continuously monitors the effectiveness of its regulations. Therefore, no sunset date has been assigned. Additionally. BFO provides the Board with an annual report detailing the Board s Financial condition. In this way, the Board continuously monitors the adequacy of its fee schedule.

Regitlatoty Review

Under section 5(a) of the Regulatory Review Act (71 P.S. § 745.5(a)), on February 21, 2020, the Board submitted a notice of proposed rulemaking to IRRC and the Chairpersons of the HPLC and SCP/PLC, published at 50 PuB. 1364 (March 7,2020) for review and comment. Under section 5(c) of the Regulatory Review Act, IRRC, the HPLC and the SCP/PLC were provided with copies of the comments received during the public comment period, as well as other documents when requested. In preparing the final-font rulemaking, the Board has considered all comments from the HPLC. IRRC and the public. The SCP/PLC did not submit comments.

Under section 5.1(g)(3) and 0.2) of the Regulatory Review Act (71 P.S. § 745.5a(g)(3) and 0.2)), on 2020, the final-form rulemaking was deemed approved by the HPLC and the SCP/PLC. Under section 5.1(e) of the Regulatory Review Act, IRRC met on 2020 and approved the final-font rulemaking. 16A-5334- Fees Final Preamble June 3, 2020

AcklitionalIIifth7;;ation

Additional information may be obtained by writing to Aaron Hollinger, Board Administrator, State Board of Osteopathic Medicine, P.O. Box 2649, Harrisburg, PA 17105- 2649, ST-OSTEOPATH ICWna.uov.

Ei,zdi,;sz.v

The State Board of Osteopathic Medicine finds that:

(1) Public notice of intention to adopt a regulation at 49 Pa. Code, Chapter 25, was given under sections 201 and 202 of the Act of July 31, 1968 (P.L. 769, No. 240) (45 P.S. § 1201-1202) and the regulations promulgated under those sections at I Pa. Code 7.1-7.2.

(2) A public comment period was provided as required by law and all comments were considered in drafting this final-form rulemaking.

(3) The amendments to this final—fonnrulemaking do not enlarge the original purpose for the proposed regulation published at 50 PuB. 1364(March 7,2020)

(4) These amendments to the regulations of the State Board of Osteopatlnc Medicine are necessary and appropriate lbr the regulation of the practice of osteopathic medicine in the Commonwealth. Order

The Board therefore ORDERS that:

(A) The regulations of the State Board of Osteopathic Medicine, 49 Pa. Code, Chapter 25, are amended to read as set forth in Annex A.

(B) The Board shall submit a copy of the final-form regulation to the Office of the Attorney General and the Office of General Counsel for approval as required by law.

(C) The Board shall submit the final-form regulation to IRRC, the HPLC and the SCP/PLC as required by law. IÔA-5334- Fees Final Preamble June 3,2020

(D) The Board shall certify’ the final—formregulation and shall deposit it with the Legislative Reference Bureau as required by law.

(E) The regulation shall take effect immediately upon publication in the Pen,,s3’h’ania Biilk’fl,i.

RANDY G. LITMAN. DO Chairperso ii State Board of Osteopathic Medicine I6A-5334 - Fees Final Annc May 27. 2020

Annex A

TITLE 49. PROFESSIONAL AND VOCATIONAL STANDARDS

PART I. DEPARTMENT OF STATE

Subpart A. PROFESSIONAL AND OCCUPATIONAL AFFAIRS

CHAPTER 25. STATE BOARD OF OSTEOPATHIC MEDICINE

Subchapter F. FEES

§ 25.23 I. Schedule of fees.

[An applicant for a license, certificate, registration or service shall pay the following lees at the time of application:

Application for unrestricted license to practice as osteopathic physician—original, reciprocal. boundary or by endorsement S45

Application for short-term camp license as osteopathic physician $30

Temporary training license or graduate training certificate $30

Annual renewal of temporary training license or graduate training certificate $25

Application for physician assistant license $30

Application for supervising physician $95

Uncertified verification of any license, certification or permit $15

Certification of any licenses, certifications, examination grades or hours 25

Application lbr athletic trainer license $20

Biennial renewal—athletic trainer S37

I 16A-5334 - Fees Final Annex May 27. 202(1

Biennial renewal—physicians 5220

Biennial renewal—physician assistants $10

Penalty for late biennial renewal—per month or part of month $5

Duplicate license or certificate S5

Application for radiology examinations $25

Appi icaLion for acupuncturist re2istration 530

Biennial renewal—acupuncturists $25

Application for acupuncturist supervisor registration $30

Application Forperftisionist license $50

Biennial renewal of perfusionist license 50

Application for reactivation ofperiusionist license $50

Application for temporary graduate perfusionist license $50

Application for temporary provisional perfusionist license 540

Application lbr genetic counselor license $50

Application for noncenified genetic counselor license SI00

Application for reactivation of genetic counselor license $50

Application for temporary provisional genetic counselor license S50

Biennial renewal—genetic counselors 575]

(a) An applicant Fora License,certificate. registration or service shall pay the followintz fees at the time of

application: (Editors Note: The blank in the first cohinin of effectivec/citesrefers to the c/citeof pubbeanon of the final—formnilemaidna in the Pennsylvania Bulletin).

2 16A-5334 - Fees Final Annex May 27, 2020

Effective Effective Efièctive July I. 2022 July 1.2024

I) Osteopathic Ph i’sician Application for unrestricted license to practice as an osteopathic physician - oriuinal, reciprocal. boundary or by endorsement $170 $185 $205

Application for short-term camp license as an osteopathic physician M.PQ £U2 S120

Temporary trainimi license or xraduate trainin2 certificate $140

Annual renewal of temporarv trainina license or Liraduatetraining certificate $25 $25 $25

(2) PIzisicia,z A ssis,aizr Application for physician assistant license 5Jn £121 $140

Application for supen’isina physician $145 $160 $175

(3) ACLIpLIIICtLIiiSt Application for acupuncturist recistration $100 $120

Application for physician acupuncturist $100 SIlO $120

Application for supervisor acupuncturist reczistration $30 $30 $30

3 16A-5334- Fees Final Annex May 27, 202(1

(4) Rcwpi,vfun’ Therapist Temporary permit $30 $30 $30

Initial license application $100 $110 $120

Licensure examination $100 $100 SI 00

Reexamination $60 $60

(5) 4tIzMic’ Trainer Application for license $100 $1 10 $120

(6) Perfhsionist Application for perfusionist license $120 $130 $145

Application for reactivation of license $105 $115 $125

Application for temporary graduate license $120 $130 $145

Application for temporary provisional license $80 $88 $95

(7) Genetic Crninse/ur Application for license S120 $130 S145

Application for reactivation of license $105 $115 $125

Application for temporary provisional license $90 $100 $105

(8) Miscellmicotuc Penalty fbr late biennial renewal - per month or part of month S5 $5 $1

4 t6A-5333 - Fees Final Annex May 27, 2(12(1

Uncertified verification of any license, certification or permit S15 515 515

Certification of any licenses. certifications, examination grades or hours $25 525 $25

DlLplicatelicense or certificate $5 55 $5

Application for radiolmay examinations $25 $25 $25

(b) An applicant for biennial renewal of a license, certificate or recistration shall pay the following fees:

November 1. November 1. November 1. 2020 - October 2022 - October 2024 - October 31, 2022 31. 2024 31. 2026 Biennial Biennial Biennial Renewal Fee and Renewal Fee Renewal Fee thereafter (I) Ostcopatlnc Ph vsician

Biennial renewal &J50- $330 42S $420 &15 $450

(2) Phi ‘sichni Assistant Biennial renewal $40 S75 $80

(3) Acupin;c/,trist Biennial renewal 540 S75 580

Biennial renewal - nhvsician acupuncturist S40 S75 580

5 16A-5334 - Fees Final Annex May 27. 2021)

Januan’ 1.2021 - Januan 1.2023- Januan’ 1. 2025 - December 31. December 3 1. December 3I. 2022 2024 2026 Biennial Biennial Biennial Renewal Renewal Fee Renewal Fee Fee and thereafter (4) I?cspi;aton’ Therapist Biennial renewal $40 $55 $60

(5) Athletic Tinitier Biennial renewal $50 £70 $75

(6) Peruiisionist Biennial renewal $75 $80 $85

(7) Genetic Counselor Biennial renewal $125 $155 $160

Subchapter K. Respiratory Therapists

§ 25.503. [Fees.] (Reseed).

[The following is the schedule of fees charged by the Board:

(1) Temporary permit $30

(2) Initial license application S30

(3) Licensure examination $100

(4) Reexamination $60

(5) Biennial renewal of licensure 525]

6 cc: during The Enclosure KJS:bmz Medicine Dear INDEPENDENT Harrisburg, l4h) Floor, Honorable Chairman the Cynthia The Jacqueline Marc Sari Stale Kenneth K. Enclosed Re: pertaining Kalonji course Harristown Board Stevens. Pennsylvania Board Farrell, Slate Final ICA-5334: George Montgomery. Bedwick: J. STATE is of REGULATORY BUREAU Johnson, A. Suter, will of a its Board to Regulation Executive Deputy Wolfgang, Osteopathic copy 2, be fees. review ft Counsel, 333 17101 pleased Bedwick, Fees of BOARD OF Acting of COMN1ONWL\LTII Director Market Osteopathic Deputy of PROFESSIONAL Deputy a harrisburg. Regulatory DEPARTMENT the final Slate to Medicine Commissioner REVIEW Chairman rulemaking. provide Street Chief of OF Post Secretary, rulemaking Board Policy.

June S (717) Medicine Pennsylvania OSTEOPATHIC Office Counsel. Unit Sincerely, State Randy whatever COMMISSION of 15, 783-3858 AND Department OF Counsel, Osteopathic Box Department of Board 2020 OF G. package I’ENSVLVANIA OCCUPATIONAL Professional 2649 Department Litman. information 17105-2619 STATE of Department Osteopathic of of Medicine of State DO., the State MEDICINE of and the Slate Slate Chairperson AFFAIRS Occupational of Commission Medicine State Board of Affairs may Osteopathic require Stephen Hoffman

From: Montgomery, Cynthia Sent: Monday, June 15, 2020 1:57 PM To: Zappasodi, Brittany Subject FW:[External]RE:Confirmation of delivery of 16A-5334 - State Board of Osteopathic Medicine - Final-Formrulemaking related to Fees

Here is the confirmation from the LRB.

Cynthia K.Montgomery Deputy Chief Counsel I JUN15 2020 of Office of Chief Counsel Department State I Commonwealth of Pennsylvania Independent Regulatory Box 69523 Harrisburg, PA 17106-9523 —______P.O. I Review Comnjjssjon 717.783.7200 Fax: 717.787.0251 Phone: I

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Protecting public health and safety. Preserving the Integrity of every vote. Promoting business excellence.

From: Leah Brown Sent: Monday, June 15, 2020 1:56 PM To: Montgomery, Cynthia ccymontgomepa.gov> Subject: [External] RE:Confirmation of delivery of 1BA-5334- State Board of Osteopathic Medicine - Final-Form rulemaking related to Fees

ATTENTION: This email message is from an external sender. Do not open links or attachments from unknown sources. To report suspicious email, forward the message as an attachment to (‘IVOPA [email protected].

Good afternoon Cynthia! The pdfs were received and have been forwarded to the Committees for their review. Willyou send us the word files once IRRChas approved this?

From: Montgomery, Cynthia Sent: Monday, June 15, 2020 1:54 PM To: Leah Brown Subject: Confirmation of delivery of 16A-5334 - State Board of Osteopathic Medicine - Final-Formrulemaking related to Fees

1 Leah —

We are trying to effectuate an electronic delivery of this rulemaking and wanted to confirm the LRBreceived it and that it didn’t go into a spam or junk folder.

Cynthia K.Montgomery Deputy Chief Counsel I Department of State Officeof Chief Counsel I Commonwealth of Pennsylvania Box Harrisburg, PA 17106-9523 P0. 69523 I

Phone: 717.783.7200 pFax: 717.787.0251

PRIVILEGEDANDCONFIDENTIALCOMMUNICATION

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— Protecting public health and safety. Preserving the Integrity of every vote. Promoting business excellence.

2 Stephen Hoffman

From: Montgomery, Cynthia Sent Monday, June 15, 2020 1:59 PM To: Zappasodi, Brittany Subject FW:Tryingto deliver a final regulation electronically

FYI.

K. Deputy Chief Counsel JUN Cynthia Montgomery I 152020 Department of State Officeof Chief Counsel Commonwealth of Pennsylvania Independent Regulatory Review Commls5lon P.O. Box 69523 I Harrisburg,PA 17106-9523 Fax: 717.787.0251 Phone: 717.783.7200 I

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The information transmitted is intended only for the person or entity to whom it is addressed and may contain confidential and/or privileged material. Any use of this information other than by the intended recipient is prohibited. Ifyou receive this message in error, please send a reply e-mail to the sender and delete the material from any and all computers. Unintended transmissions shall not constitute waiver of the attorney-client or any other privilege.

Protecting public health and safety. Preserving the Integrity of every vote. Promoting business excellence.

From: Wills IV,Victor [email protected]> Sent: Monday, June 15, 2020 1:58 PM To: Montgomery, Cynthia Subject: RE:Tryingto deliver a final regulation electronically

They both confirmed receipt.

Victor

From: Montgomery, Cynthia Sent: Monday, June 15, 2020 1:48 PM To: Wills IV,Victor [email protected]> Subject: Tryingto deliver a final regulation electronically

Can you contact Jen Smelz and Marlene Wilson and ask them to confirm receipt of the delivery of the Osteo Board’s final-form rulemaking today? We have confirmation from the two other ExecDirectors.

Cynthia K. Montgomery Deputy Chief Counsel I Department of Officeof Chief Counsel State I Commonwealth of Pennsylvania

1 P.O. Box69523 Harrisburg, PA 17106-9523 I Phone: 7177837200 Fax: 717.7870251 I

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Protecting public health and safety. Preserving the Integrity of every vote. Promoting business excellence.

2 Stephen Hoffman

From: Livingston,Jerry Sent: Monday, June 15, 2020 9:43 AM To: Zappasodi, Brittany Subject: RE:Regulation Delivery16A-5334

Received for the office of Senator LisaBoscola. I JUN15 2020

Indepencsen - J Regulatory J.J. Livingston L_ Review Commission Executive Director Senate Consumer Protection & Professional Licensure Committee

Tmp. Cell (717) 480-0108

Office of State Senator Lisa M. Boscola 458 Main Capitol Building Terry.Iingstontasenate.com

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From: Zappasodi, Brittany Sent: Monday, June 15, 2020 8:34 AM To: Bulletin Cc:Livingston,Jerry cJerry.Livingstonpasenate.com>; [email protected]; [email protected]; [email protected]; [email protected] Subject: [WARNING:ATTACHMENTUNSCANNED]RegulationDelivery16A-5334 Importance: High

• EXTERNALEMAIL.

Pursuant to SR 318 and pursuant to the letter from House Parliamentarian dated March 25, 2020, authorizing the Legislative Reference Bureau to transmit regulations to the appropriate committees for consideration, we are submitting Final Rulemaking of the State Board of Osteopathic Medicine — Fees (#16A-5334) to the House Professional Licensure Committee and the Senate Consumer Protection and Professional Licensure Committee.

Please provide written (email) confirmation that this rulemaking was received by each of the offices of the respective Committee chairs.

1 Legal Brittany Zappasodi I Assistant Counsel Division Legal Office Department of State I 2601 North Third Street, P.O. Box 69523 Harrisburg, PA 17106-9523 Fax: Phone: 717.783.7200 I 717.787-0251 www.dos.pa.gov

PRIVILEGEDAND CONFIDENTIAL COMMUNICATION The information transmitted is intended only for the person or entity to whom it is addressed and may contain confidential and/or privileged material. Any use of this information other than by the intended recipient is prohibited. If you receive this message in error, please send a reply e-mail to the sender and delete the material from any and all computers. Unintended transmissions shall not constitute a waiver of the attorney-client or any other privilege.

2 Stephen Hoffman

From: Nicole Sidle Sent Monday,June 15, 2020 10:30AM To: Zappasodi, Brittany;Bulletin Cc: [email protected];[email protected];[email protected]; [email protected] Subject RE:RegulationDelivery16A-5334

JUN152020 Received. IndependentRegulatory — Review Commission From:Zappasodi, Brittany Sent: Monday,June 15, 2020 8:34 AM To: Bulletin Cc:[email protected]; [email protected]; [email protected]; NicoleSidle ; tblauchpasen.gov Subject: RegulationDelivery16A-5334 Importance: High

Pursuant to SR 318 and pursuant to the letter from House Parliamentarian dated March 25, 2020, authorizing the Legislative Reference Bureau to transmit regulations to the appropriate committees for consideration, we are submitting Final Rulemaking of the State Board of Osteopathic Medicine — Fees (#16A-5334)to the House Professional Licensure Committee and the Senate Consumer Protection and Professional Licensure Committee.

Please provide written (email) confirmation that this rulemaking was received by each of the offices of the respective Committee chairs.

Legal Brittany Zappasodi I Assistant Division Office Department of State I Counsel Legal 2601 North Third Street, P.O. Box 69523 Harrisburg, PA 17106-9523 Phone: 717.783.7200 Fax: 717.787-0251 www.dos.oa.pov

PRIVILEGEDAND CONFIDENTIALCOMMUNICATION The information transmitted is intended only for the person or entity to whom it is addressed and may contain confidential and/or privileged material. Any use of this information other than by the intended recipient is prohibited. If you receive this message in error, please send a reply e-mail to the sender and delete the material from any and all computers. Unintended transmissions shall not constitute a waiver of the attorney-client or any other privilege.

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1 Stephen Hoffman

From: Wilson,Marlene Sent: Monday,June 15,2020 1:56PM To: Zappasodi, Brittany Subject: RE:RegulationDelivery16A-5334

Received. Thank you.

JUN•1’52020

Independent Regulatory ReviewCommission Afa-tteneWiLin, aqLL&c - SeniwcCommittee&recutiue !Dkecto4 J&e .9wiiionat £icenaute Conunutee IRep.JLa ea&&aw, Cfiaimwt 107 Swk Cf LBaiMing 9)j9 LBoa202036 3Eaio6uw, I? 17120-2036 9hsne: (717) 787-4032 Intemat 96mw: 6253 CoIL(717) 645-9967 wc: (717) 772-9862 (snail - mwi&on(pafinaoe.net

From:Zappasodi, Brittany Sent: Monday,June 15, 2020 8:34 AM To: Bulletin Cc:[email protected]; [email protected]; Wilson,Marlene ; [email protected]; [email protected] Subject: RegulationDelivery1645334 Importance: High

Pursuant to SR 318 and pursuant to the letter from House Parüamentarian dated March 25, 2020, authorizing the Legislative Reference Bureau to transmit regulations to the appropriate committees for consideration, we are submitting Final Rulemaking of the State Board of Osteopathic Medicine — Fees (#16A-5334) to the House Professional Licensure Committee and the Senate Consumer Protection and Professional Licensure Committee.

Please provide written (email) confirmation that this rulemaking was received by each of the offices of the respective Committee chairs.

1 Legal Brittany Zappasodi I Assistant Division Legal Office Department of State I Counsel 2601 North Third Street, P.O. Box 69523 Harrisburg, PA 17106-9523 Fax: Phone: 717.783.7200 I 717.787-0251 www.dos.pa.pov

PRIVILEGEDAND CONFIDENTIALCOMMUNICATION The information transmitted is intended only for the person or entity to whom it is addressed and may contain confidential and/or privileged material. Any use of this information other than by the intended recipient is prohibited. If you receive this message in error, please send a reply e-mail to the sender and delete the material from any and all computers. Unintended transmissions shall not constitute a waiver of the attorney-client or any other privilege.