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‘Commonwe: h of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, MA O2111 (617) 727-3086 bbuipuiwww.massmedboard.org Physician Registration Renewal Appli sreea-envelope d weeks before your renewal + Remit $250.00 for renewal fee, { + Add late fee of $25.00, if necessary! Please re alterations as required. L Current Status: Aggive Ciretiring (cee instructions) Wasie 2. Other Name(s), if any, under which you were licensed: 3. A) Mailing/Rusiness Address: CATHRYN L SAMPLES 1B) Home Address: Home Phone: Business Phone: Registration No. 47853 € you want fo change your current status, please check one of the following boxes to indicate your ew status: (Check only one) inactive (sce instructions) fore proceeding please ead the instruc ETAT cords you wit tee cope fr eedenalng and ater purge WD cdb de Bel ered aah + encipse eneck with coupon in BLUE envelope. careful he following ib PROTEGE dud completeness Make any corrections or Renewal Date: 11/06/2001 Co aot wish to renew Please make corrections (type or print) aling Adaress: CitsTown: Bee ter Zip: Country isms Adige Re, Cityrtown: Ste mA Zip: 02-115 County: aa Business Telephone: (oJ? ) ‘Cou eee ome Telephone: ( a ‘| PLEASE NOTE: No P.O. Box addresses for nome or business addresses. AUB, Other Name(s): ol ¥ 4 a Dat of Bit see, ©) SS#: 5. a) Name of Meu School ty VERB RRREEY Schoo! or Mics 6 Specialty Codes) (See Tabie 1) Mo. 7, Curcent American Board of Medical Specialties Certification (See Tebie 2) Piode: PEO} Code: 8, Drug License Numbers, if any: i: a) Fedcral (DEA): ) Massachusens: ) Other states where you are mow licensed to practice (Abbr.) Code(s) Hours ver Week in Mass. ») States where you were previously licensed (Abbr.) PD 0 ——_~ediatries BUY ert erect eed cee cece DA_0_Adolescent Medicine 10. Current health care facilites at which you have completed the credentialing process forthe provision of patient care. (Supply the codes from Table 3 and place a check mark next to those healthcare facilities where you have adnuiling privileges (AP). Next io each facility, write the approximate percentage of patient care hours that you provide in each facility). Facility Coe: % Pacy Coie] JQ) pa0) 2.6 0 Fay Clef caby_% ~~ scl Code: “/(AP)e_— % Fal Coce'f 3 GV (AP) 79% Fucy Code ~~~ (an) Tose eat bit "Healthy Pember ~~ sates PRINT YOUR LAST NAME: SamPces LICENSE NUMBER: 6/2263. 11, My medical malpractice insurance is covered by a) [Flnsurance Carrier b) (]. Letter of Credit so Name of fnsarer__© RACO Alternatively, indicate as follows: . ‘Lam registering with Active status but I am not covered by medical malpractice insurance hecause 1 am (check one) 2) C)_ Notinvoived in direcvindirect patient care in Massachusetts b) [] Otherwise exempt Please explain exemption eee 32, Are you curently ina post-graduate tring program in Massachuses as a resident or clinica fellow? (check one) [] Yes JSNo 13, A, What is your principal work setting? (See Table4) _\' © B, Care of patients in Massachusetts (see instruction booklet). I Average weekly hours involved ia: a) owparientcare 1B _hrswk b) inpatient care “frank 2) Whar is the approximate percentage of your patient care kours in primary care? Db % = ¥ iE PAST TWO 14. CLAIMS MADE: Has any medical malpractice claim-been made sgainst you.that has not yet been finally... | settled or adjudicated, whether or not lawsuit was fled in zelation tothe claim? 15. CLAIMS RESOLVED: Has any medical malpractice claim that bas been made against you been setled, adjudicated, or otherwise resolved, whether or nota lawsuit was filed in relation to the claim? 16, Has any lawsuit, othr than a medical malpractice suit, whic is elated to yous conapetency to practice medicine, ox your profestional conduct in the practice of medicine, been filed aguinst you or been seted, adjudicated or otherwise resolved? 17, Have you been charged with any criminal offense, other than a minor traffic violation? 18, Have you been charged with or disciplined for any violation of laws, ules, by-laws of standards of practice of ‘ny governmental authority, health care facility, group practice or prStessional society or essotition? 19. Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied, resticted by, or surendered to any state or federal agency? ‘ 20, Have ,cu withdravm an application for & medica iense or been denied a medical license for any eason? 21. Has any ofessionl lability insurance provider restcted, limited, terminated, imposed a surcharge or co-paymer or placed any condition related to professional competency or eanduct on your coverage or have you vohuon ly estrcte, limited or terminated your insurance coverage in response fo an inquiry by a profesional liability insurance provider? 22, CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date?” [3h Yes. [J No 1 Ce Waiver requested (CME waiver frm due 30 days prior to date of icnse expirtion) O cat exemption ‘See Instructions for CME requirements. Do not submit documentation of your CMEs with your renewal application. Pursuant iS GATE 112, § 3 LWlna care oor collec ii a Medlee Venefitry Bore than the Medicare fee schedule aot Pursuant to GL. ¢.62C, § 49A, tothe best of my knowledge and bel, Have led all Massachasets sat tax returns and pal all Massachusts state taxes hat ae required under lam. NOTE: Ths apples even if you reside outo-taeor out of the United States + Pursuant to GL c. 2C, §47A, to thebestof my knowledge and belief, Iam ix compliance with M.G.H.C, 119A relating 19 withholding and remiting Child Suppor. + Pursuant to GL. 112,614, Twi fll my obligation to report abuse or neglect of children as required by Gel. 119, 8S1A. + hereby certify under the penglies of gerjry that all hg ipformation on the Renewal Application and Form R is true, dare: 10.) 1S OL. aT A ENEW, ul yu moti urd, in writin {ress : MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING” 2 Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320 Physician Registration Renewal Application Before proceeding, please read the instruction booklet, * Copy this form and all attachments for your own records; you will need copies for credentialing and other purposes + Remit $250.00 for renewal fee + Return renewal application ia GREEN envelope, + Add late fee of $28.00, if necessary. + Enclose check with coupon in BLUE envelope Registration No: 42863 ‘Renewal Date: 11/06/1999 1. Current Status; Acti | If you want to change your current status, please indicate below: (Check one). [Mh Active (Cl Retiring (see instructions) Li lnactive (sce below *) Odo: yee 2. Otter Name(s), if any, under which you were licensed: Please make corrections (type of pnBaaisuaion i Mocicine Other Nametay 3. A) Mailing/Business Address: CATHRYN L SAMPLES Peer eeara ity’Town: Zip: 1B) Home Address: Home Phone; Home: (_), Business Phone (1) 97 J=2.132. Baie: 4, A) Date of Birth: Sex: F Das of Binh: (DY: _/_/_ Sex: JM) F B)SSH: eee eee Full Name of Medical Schoo! 5. A) Name of Medical School: ‘Tulane University School of Medicine B) Year Graduated: 1973 ©) Degree: MD. Year Graduated: Degree: J MD. DO. 6, Specialty Code(s) (See Teble 1) (Codetsy "ays Per Week in Massachusets Sppels) Hours pe Werk in Mass, Ene lg Seacrest aH eeeeea eee 2 ADA 0 Adolescent Medicine fac Fir pect: 7. Current American Board of Medical Specialties Catfction (See Table 2) [Coie PE toe PEI] Code: PE Code: 8. Drug License Number, ifsny: dani EAN ‘) Federal (DEA): ore B) Massachusets: ees 9. A) Other states where you sre now licensed to practioe Abbr: Abie sees acer ece 'B) Stes where you previously were licensed to prestice ‘Abbr: NY CT CA Abbr: “If requesting Inactive status, you agree not to practice medieine, including writing prescriptions, in Massachusetts, 6 PRINT NAME AND NUMBER: Last Name: Samo. a Registration Number: {28% * 10, Curent health car facilities at which you heve completed the credentialing process for the provision of patent care. Supply” = the codes from Table 3;and place a check mark next to those health care facilities where you have admitting privileges (AP). Next to ‘each facility, write the approximate percentage of patient care hours that you provide in each facility. Facility Code: / BY) W~ (AP) s00_ % Facility Code: —/__(AP)_% Facility Code:____/_(AP)_ % Faeilty Code: 7 1999, print name(s) 11, My medical malpractice insurance is covered by a) fp Insurance Carrier) [] Lett of Credit Name of insurer, CRTCO - ‘Ahtematively, indicate as follows: Lem registering with Active status but I am not covered by medical malpractice insurance because Iam (check one) 8) (J Not involved in irectindirect patient care in Massachusetts.) [] Otherwise exempt Please explain exemption: _— _ 12, Are you currently in a post-graduate training program in Massachusett'as a resident or clinical fellow? (check one) [-] Yes JX{No 13, A. What is your principal work setting? (See Table 4) 2 S_ B. Cate of patients in Massachusetts (see instruction booklet). 20 1) Average weekly hours involved in: 2) outpatient care SB hrs/wk b) inpatient care ZB _hesiwk 2) What is tho approximate percentage of your patient care hours in primary cre? 7.0% = RON! 0 14, CLAIMS MADE: |Has eny medical malpractice claim been made against you that has not yet been finally ‘settled or adjudicated, whether or not a lawsuit was filed in relation tothe claim? 1S: CLAIMS RESOLVED: Hasan mei malpasice cin tas een mae agit you btn ste, adjudicated, or ‘ise resolved, whether or not a lawsuit was filed in relation to the claim? ‘16, Has eny lawsuit, other than a medical malpractice suit, whi related to your competency to practice medicine, of your professional conduct in the practice of medicine, been filed against you or been settled, adjudicated or otherwise resolved? 17, Have you been charged with any criminal offense, other than a minor trafic violation? | 18. Have you been forshally charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of any governmental authority, health care facility, group practice or professional society or association? 19. Has your priviloge to possess, dispense or prescribe controlled substances been surrendered to or suspended, revoked, denied or restricted by any state or federal agency? 20, Have you withdrawn an application for a medical license or beon denied a medical license for any reason? 21. Has any professional liability insurance provider restricted, limited, terminated, imposed a surcharge or ‘co-payment, or placed any condition related to professional competency or conduct on your coverage or have you voluntarily resjricted, limited or terminated your insurance coverage in response to an inquiry by & professional liability insurance provider? 22. CME-CERTIFICATION: Have you completed your CME requirements preceding your renewal due? Jf Yes [1] No (C) CME Waiver requested (CME waiver form due 30 days prior to date of license expiration) 1 CME exemption ‘See Instructions for CME requirements, Do not submit documentation of your CMEs with your renewal application, + Pursuant to GL. c.112, §2,1 wll nt charge t oF collect fom a Modiare beneficiary mare than the Mediro fee schedule smount. + Purnuant to G.L.c. 62C, §49A, to the best of my knowledge and beli, Ihave filed all Massachusetts state tax rsturos and paid ll ‘Masachasttsstateltares that aro required under law. NOTE: This applies even Ifyou reside out-of state or out ofthe United States. Signature: aaa ‘YOU MUST SIGN AND INCLUDE WITH YOUR RENEWAL APPLICATION JOARD OF REGISTRATION IN MEDICINE ROOM 1507 — 100 CAMBRIDGE STREET BOSTON, MASSACHUSETTS 02702 RENEWAL APPLICATION 1986-1988 meORTANT PURSUANT 70 W.GL © 626, UNDER Hie benaiec of veh BES agi OSE AN GELIEN HAVE FILED ACL Fe AR METORNG YOU PADD ALC BATE PARES 1EAO, COMPLETE AND SIGN — SEE AEVERSE SIDE Ce YOU ARE REQUIRED 10 COMPLETE THE QUESTIONS. ON THE REVERSE SIDE OF THIS APPLICATION. ste “THE ENCLOSEO INSTRUCTIONS FOR DETAILS) IF YOU ANSWERED “YES” TO ANY OF THESE QUES: ‘Siu “TONS, YOU MUST CHECK THis 80x: [_] PLEASE USE THE ENCLOSED RETURNENVELOPE TIS APPLICATION AIST BE SIGNED AND ac Te ——| fwowns | eee [Eepeneee] Uerevee] NOTEL SELES WI Sapa rs) 2863 | 100-00 }106.00| 01/15] 86) | a. setae OES carom 1 sanrues Saanae comunmetteranenusers a ee Saat boston wacencrunerr eet 3500600426631 011586 10000000004 DIVISION OF REGISTRATION ‘ROOM 1520 — 100 CAMBRIOGE STREET SOSTON. MASSACHUSETTS 02202 WensWal APPLICATION BCARD OF REGISTRATION IN MEDICINE AS A REGISTERED PHYSICIAN Sate 42863 100.00 [190-90 IMPORTANT — READ, COMPLETE AND SION — PURSUANT To GL C420. Sata. CERF NBER THE bellies of BERGA THAN TO My BEST RnOnceSAe ane oeuEr Cave fees ate STATE TAR REVERS ANG PAD LCSTATETARES ReOUingD dnoee ta Bay Tais Eg @ CATHRYN L SAMPLES MY SIGNATURE ON THIS RENEWAL APPLICATION INOIGATES THAT T ATTEST UNDER THE PAINS AND PENALTIES OF PERJURY To THE COMPLETION OF CUNT INU ING | OUCATION REQUIREMENTS IN “COMPLIANCE WITH THE BOARD'S STATUTES AND/OK KULES AND REGULATIONS. PLEASE USE THE ENCLOSEO RETURN ENVELOPE Votel TES ARRLOATION, must, Be. SIGNED AND AETUeNED TN "GertiFlED GNECK OR MONEY ORDER” PAYABLE TO: S COMM, OF Mass. P.O. BOX BOSTON, MASS. 02297 UNCERTIFIED PERSONAL CECKSBUSINESS. SHEERS Witl NOT BE ACCEPTED 3500600428631 011584 10000000009 1. Paneipat Ce et ae emt 3 Val hh 4 mi te 175 Dud. Sr | Rox tomy MB. 0219 oY, ea, er Lak extredttce ne 3B. Hots Aldea 97 bias your privilewe to pousess, disperse oF prescribe confeolled subslanucs ever boon suspéndad ur Tevoked l frets stale or aay attiee! 10. thaws compe nanonts hatwoon Wigae & v15i64 ws tottows:® LO] AL Lol rzL Hy GME re THEREBY CERTIFY UNDEN UM PENALTY OF PERUUIEY IAT PE ABOVE itd ORMATION 1S TRUE, * SEE CODE SHEET (vou Cato 1S1-9568 10/09/36 Pager 2 cnueetce gard of neptstraon in nadtoine ph a ‘ O° wis CATURNN L. SAMPLES, 2 1. Hhysietan Information Aly The information in sections I - V hus been provided by the physician. Dr. OAMELRG has Deen Licensed Dy Masnachusette fori 38 youre Accepting new patente? Yer \——sAacapta Medicaid? Yew Primary vork aattings otnar Business address: MARTHA RLTOT xeanrit\CTR ‘75 BICKFORD STREET QAMAICA PLAIN, WA 02439-1401 Phones 617-991-2100 ptate path Translation sarvices avetlabler tone = RY + clang insurance Plane Accepted N\ pspitel attildations Juewt om Mysobberhood meaith Pian Ka Hospital S pansh Brucare 2 futte HCH P Cetra iol) ooref 1o/ fae IT. Hdyeation 6 graining Medica, school: Tulane Univaraicy School of Medicine faduation Date: 1973 Post Graduate Training: 07/01/73 - 06/30/76 Montafto: Hosp TIE. gpecdalty diateice, Adoles ard Certified: IV. Honors and Awarda IN THM BEST INTEREST OF TRE CHILDIEN. RATNDOW RECOGNITION AKARD 1995, FOR SERVICES TO YOUTH LIVING WITH HIV/ArDS ¥. Professional Publications hie physician has reported ne publications. VE, Malpractice Information Jone studies have shown thar there is ne significant corpelation between malpractica history and a doctor's comp e the suma tine, the Board ves that consumers should have accega to malpractice information. In formation about both the maipractica eialty and the phyaiedan'e history of paynen' history of the physician's he Sotrd. hee placed, payeent,angunes into threw statistic) sateporigey below Sac? above aver fest nanan trate elas spective. You could mias an opportunity: Tor ahie Hughie higanedOe MEL, Beetle dans tpeetase Serta ins peta Sethe subset’ of iieigations. tal Sa se aie ne ER, average, average, yon phoiad’ ipo tnd sno for high quality When cone: dering ps Malpractice Bistors Likely’ than others gnly fo. the em Gnalvidual doctor’ ZO"d yOO"ON Zz:8 96,91 190 Bé76e862t9:01 312 HLTH LOITa bHLabH WARTHA ELIOT HLTH CTR 1D:6179839478 SEP 26°96 20:04 No.021 POL &— PHYSICIAN PROFILE (information current as of 8/21/96) Cathryn L Saunples: 1. PHYSICIAN INFORMATION ‘The information in Sections 1, 1] and 111 has been provided by the physician. ) Marthafliol Health Canter, na surance Plan petites 75° i cher d St, ions WP Bickford St. Afflintions damaice Plain, MA 02130-1402 Neighborhood Health Plan usa Hino Blue (617) 438-6888 977 1-210 Pincere Tatts Hospital AMfitiations Chitdren’s Hospital r Tr 1. EDUCATION AND TRAINING Medical School: Tulane University School Of Meglicine 73 Post-Graduate Training: Montetiove Hosp 07/01/78 W716 WL... SPECIALTY. BOARD CERTIFICATION Pedisivies Hoard Of Pediatrics — 197% Certs Cred) Adolescent Medicine EB Uigihe For Sabsgeciath, woarda Iv. HONORS AND AWARDS Up to six entries may be included. Completion of this Porto of the profile bythe physician is entirely voluntary. In The Best Intevest OF The Chilérou, Rainbow Reco Gition Award 1985, For Services To Youth Living Wit &TV/ A 0S Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1995-1997 Physician Registration Renewal Application RegisuationNo, Samus Fee Renewal Date Le Fee 42963 ACTIVE. $250.00 31/96/95 $25.00 Corfvetion of Malling Adress ‘Malling Address: “Aliress (Malling): CATHRYN L SAMPLES, M.D. Gipffown, Stat: Country: Directions: Hefore proceeding, please read th instruction bocklet. Some questions are optional + Failure to renew in tnely manner wil cause your lense to lapse and may affect your abluty fo practice medicine in the Commonwealth. (See enclosed letter). + Add tute fe i necessary. + Make a copy ofthis form and all attachments for your own records - you will need copie for odentalng and ether purposes. ‘The Board will charge a fee foreach copy it provides, + Ses instructions on detachable coupon at bottom ofthis page. FORINE Pre-Printed Information Corrections of Pre-Printed Information 1, Other name(s), if eny, under which you were licensed: 2.Business Address: 33 BICKFORD STREET JAMAICA PLAIN, MA 02130 3. Dat of Bik: Sex: ¥ Dawe of Binh (M/DIY): LL Sex (Me Ue. sue Date: 96/14/78 S84 J Lie, sue Date (MID/Y): L Home: (_) Business: (_) Full Nam of Medical School Home Phone ‘Busineas Phone (617) 522-5300 4, Name of Medical Schoo Tulane University School of Medicine YearGradowed: __Degzee (DIDO Your Graduated: 73 Degree: MD prc 5. 2) Other sates where you are now Licensed o practie (Abb): ») Stes where you previously were licensed to practice (Abbe: NY CT CA. 6, Specialy Code(e) (See Table 1): Code Howe per Week in Muss, PD 10 Pediatrice ADA 25 Adolescent Medicine 7, you are currently American Specialty Bourd cenified, enter codes: (See Table 2) Code: PE, Coe: 5. Drug ioense number) if any: 4) Federal (DEA) b) Massachusens edz (DEA): Mass 9. -Aiviy Suns: um appyeg tobe cepted with te folowing sacs ACTIVE X iNacrIVE + Kerby cry that requesting Inactive atts wl ot prac mea, nang welt presrptiony a Manachusts PRINT NAME AND NUMBER: Piysician ipst Name: CLES Regisvation Numer: f 2B 3 _ 10. #) Curret heath care facilities) a which you have caopleted the redensling process for he provision of pair cre. Supply the coves rom Teble 3 wd place a chock mg next wo those faite where you have admiting aivileges (AP) Facility Code: AAG. / a2 (AP) Facility Cie: fm (AP) Facility Code: (AP) Facility Code: J (AP) Facility Che.) (ap) Facility Code: ___-__ (ap) 1999, print name(s: ) Additional hospitals at which you previously held pxifileges and other healthcare facies with which you were associate inthe past 2 years. (Gee Table 3) Facility Code: Pacily Code: _____} Fucitiy Code: Facility Code: Facty Codes 17999, write name(e): 1. My model susie aan sped by (I x it __ A applicable, check one E staus, bat Lam not covered by medical malpractice insurance because I am Atuernatvely, indicate as follows: Tam registering with AC} fin Maseachasett: —_—— (i) Otherwise exempt: ——— (Check One): (i) Not involved in dsectindires patient cur State how otherwise exempt 4) How many hours per typiced week are you: Treen oupat carey Mas? 4i) How many hours per typical week are you ct involved in inpatient care in Mass? — B.S sik ©) Apnroximately what percentage of your patient card hours ere in primary care? (See instrctions for definition of primary care) 20 % (Queson 1 through 24 sfc Co the pst cwo years hy. Check cer YES o: NO (NOT N/A) teach question. rove dis on Forms R-1 and R-2 forall YES answers. Refe yes NO 15. CLATMS RESOLVED: Has any medical malpractice hn ga yo be ee tendo eerie whether or nota wit was fled in relation thee 16 Has ay lawsuit ote than a medial malpractice sit, ich seated to your empeteney to pees medicine, or Your po ‘eso conn be pate of mdi bm le gin you bys pte, oben ee jad or obkrvise resolved. 17 Have you ben chrged wih ny ciminlofeass| 16 lve you been forall charged wit odsilined orf violation ofthe ue, by-lws rwanda of pac of exy severance, eh ee frig, romp : "or rected by any sate ordeal agency? 20. lave you witezeon an application fora medical Licendpor bem denied a medialis fren reason? 21, Has any profesional ibility insurance provider resicfd Limited, rma or imposed a surcharge on your coverage ot you erly esc remap i vege iene yy pee Tian ieaurnoe prove omer : 22 Have yo been ingnoaed wid or do you have «matic cndon which iis or ipa your sity pra nding? 23. Have you engeged inthe we of any chemicel substance) which in eny way intrered with your ability 0 pacice? 24. Have you voluuarily modified oc otherwise led yf scope of pace of medicine fr any reason ter than a medial cout? eee 25, Thave complet my CME requirement in he two yes proceding my renewal dee: Yes ~~ No, waiver equi, ae No, ining rogram exeasptin (so intracion bok. ‘Hvequesting 1 waiver you mus low a separate Waife orn, The waiver mut be granted by tne Board before your cease wil be renewed. See inmtions for CME reqirerents. Do ot abt documentation of your CMES with yous renewal aplication, + Pursuant to G.L.c. 112, sec. 2, Tl not charge oof collect from a Medicare beneficiary more than the Medkeare reasonable charges. + Pursuant toG.L- 62, sec. 494, Thereby erty fer tbe patos and penalties of perjury that, to he best of my knowledge and belt, have fed all Massachusetts late tax rears ad pald fH Messachusets oe taxes tha! are required wader lew. NOTE: This epples ven yn re otto the Unite Sats * Parsuant to Gil. c. 112 so, 1A, bereby certify Gc. 19, 00.814, 12858,0000 1, PHYSICIAN INFORMATION THRYN. et le eH non SAMPLES. : mh. He de iad Tea Nome m0, mbt Make changes te iaié here Be Mass License #. 42869... First Issue Date 06/14/78. License Status. . Active Hospital Affili Aelolescent Ov ecter- ee ee Siento 8 Giidten espa clams Plain, MA 02190-1401 USA, (617) 522-5300 X216 Make eidress conrecions here Make any corrections t0 above tire: Bddolastred/ crated Prog ren : 7 — Coit Ct, moo.Longuiood Ave i a Boston MAO ao~ cae ‘Licenses Held in Other States NNR, NorBine, Peastace, TRE cn (Please correct as necessary) Tl, EDUCATION & TRAINING ‘Tulane University School of Medicine wp 73 Medical Schoo? Degree Pep ere oer recreate “Maike corrections here “Paes pics : corre /; Mont eSiore Hospital, Bem Wl lid 2D rnd... ‘Residency Programis) aa é i - a Bi... Residenes Prograniis) ‘Siant End ‘Residency Programs) Sant IIL, SPECIALTY BOARD CERTIEICATION Primary Specialty: Podiatries Certifying Board Name: Board of Pedistrics Secondary Specially: Adolescent Medicine Certifying Board Name: Make any corrections here: Make any corrections here: Board of Registration in Medicine Physician Profile ' 12858,0000 TV. BOARD DISCIPLINE Final Decisions and orders issued by the Massachusetts Board of Registration in Medicine. Nature Date Board Action NOVE V. HOSPITAL DISCIPLINE Hospital Date Disciplinary Action VOWE VL. ONVICTION: ‘The Board of Registration is unable to obtain accurate data for this category atthe present time. This information will be included when the court system is fully computerized, Please list any criminal convictions. Include conviction date and nature of complaint pi é Banaras ctr LV OPE a aa ‘VII. MALPRACTICE Fe c na No. of Years in Practice: # /@ Details of claims paid for Dr, SAMPLES + Date, owe. Amount Paid 0.0000. Basis for Complaint Date ‘Amount Paid Basis for Complain : : Date ‘Amount Paid “7 Basis for Complaint ieee eer Date, _-- Amount Paid Basis for Complaint isi Date moun ald Basis for Complaint ca Date ‘Amount Paid Basis for Complaint ~~~ ef fi VIN. PHYSICIAN HONORS & PEER-REVIEWED PUBLICATIONS 1 Please enter any peer-reviewed publications to which you have contributed and any’ awards for community service or professional recognition you have been given Awards, Honors Publications Lnthe Gest Later satel (he... eter Bear Zr a Children Raabe Re cgg Aint cee een . Brod li49s) ~$ ac.servicer to SEs ac eee EEE Yyowdtdr Living th TW ee cee nm a Note: Please return the survey In the enclosed envelope to: Atlantic Associates, Inc., 8030 South Willow Street, Manchester, NH 03103 i Board of Regletration In Medicine Physician Profile Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1993-1995 Physician Registration Renewal Application tee Correction of Malling Address: “Address (Mailing) : Gigitows— Sites ‘County Code (See Table 1) Directions: Staple check to bottom of form. Add late fee necessary. + Questions 1-8 include information fom Board files. Please corect as necessary in the boxes ‘provided on the right hand side of te page, + Before proceeding, please read the instruction booklet. Some questions are option ‘Make a copy of this form and all attachments for your awn records - you will need copies for credetiaing and other purposes. The Bosrd will charge a fe for exch copy it provides. b + ncloce the $250.00 renowal fee by means of a ceified check, money order or personal check made} payable wo the Commonvealth of Massechuseus. ‘Pre-Printed Information Corrections of Pre-Printed Information 1, Other name(s), if any, under which you were licensed 2.) Address (Home): “Zip | — 11989 print County: ———____] ) Address (usiness): : sFuRh QTheeT Couniry Code= T1995 print County JAMAICA PLAIN, WA Uetow 3 jin ast Dae of Binh (MID): —L—L— Sex (M/F Cece Dues G5 114/78 oo Lic. Issue Date (MID/Y: J SSH phone Nar ee ‘Telephone Number: nao Home: (_) Business: (_) fens Business : ‘ ott) 522753509 aaa 4, Name of Medical Schoo!: : ; Tulane daiversity genool of hedicine ‘Year Gradvated: ‘Deg (MD/DO}. __ ‘Year Grasusted:? 5 oe 5. 2) Other states where you are now licensed to practice (Abbr): ee eee Pee 1) Sines whee you proviouly were licensed topractce (Abby: NY TCA aE SE SEG Cate Tar or Wek nae 6, Spciahy Codes) (ee Table 2 -P og eesenecee ole Howe pes Werk ig Mass, FLSA ae 4D jatrics [eae AvA 20 Agolescent Medicine 7, 4) Ifyou are currenily Americen Specialty Board Certified, enter Codes: (See Table 3) code Fe ‘Code: Code: Code: 2B) Ifyou previously were American Specialty Board certified, tut are no longer, please ener cores of prior ceificalion: (See Table 3) ee pve Code: Cote: 4, Drug License Number(#)if any: 2) Federal (DEA) Federal (DEA. Sia (MA) State (MAY. 19 Lnave completed my CME requirements in the two years preceding my renewal date: Yes No, waiver equestod Yours illonta spas Waiver Foun, The waiver at be gmt by the Board ore Jour Hoos wi be reneted. Soe insuctons for EME egiements. Bo not submit documentation of your CMEs is your renewal ppicaton e QF \ List insurer Ateratively, indicate as follows: \am registering with ATIVE status, bat am not covered by medical malpractice insurance because Lam (Check One}: (@) NOT INVOLVED IN DIRECT/INDIRE ute how oer xem ‘pat Cose ESO Low ty Fetiy Cote 16999, print name(s): ‘Adcivional hospitals at which you previously held prvilefes and other health care facdities with which you were associated inthe past 2 years. ilies where you have Code: ns | (AP) Facility Code: — a —! sectip cae OD. rusty cate: (2. & Srey cots Psy Cad yc 1999, write name(e: 13. Are you currently in a post-graduate taining programfin MA 4s a resident or clinical fellow? Yex__ Nt (creck om) 14, 0) Whetis your principal work ating? (See Table) QS ) Cae of patients in Massachusetts (MA) (See inutrftion booklet) 4) How many hours per eypial week are you! ‘involved in oxtpatien cere in MA? DO. trs/wicin MA 42) How many hours per typical week: are you curfently involved in inpatien! care in MA? i hrsfwk in MA. Questions 15 through 23 refer Provide details on Form ISA forall YES answer. 15, Has any meical malpractice claim been made against pou, whether or not lawsuit wat fled in elation 40 the ait? son YES NO 16, Have you been charged with any criminal offense, othf thn a minor traffic violation? 4 Hime you foal een hace wit iin ay von fr yao andes of psi of ny governmental authority, health care facility, group price or profestinal sciery or association”. 18, Has your privilege to posses, dispenue or prescribe cqhtolled substances been surrendered to ot suspended, revoked, denied cor reatricid by any state or federal age20Y? wanna nn 19. Have you withdeawn an application for « medical Licedge 0° :~vn denied « medical license for any reeton? 20, Have you had eny menral liness which has impaired ypur ability to practice medicine or o function as a student of medicine? pendent upon sleohol or drugs? ed, Limited, terminated or imposed a surcherge/on Your coverage? 22, Are you now, cr have you been in the past two year, 23 Has any profesional lability insurance provider ‘+ Pursuant fo G.L. ¢.112, see. 2,1 will not charge tor collect from a Medicare beneficiary more than the Medicare ressonable charges. + Pursuant to G.L.€. 62C, sec. 49A, 1 hereby certify nder the penalties of perjury that, tothe best of my knowledge and belle, Ihave Med all Massachusetts state tax returns and pald all Mipsachusetts state taxes that are required under law, NOTE: This applies even if you reside out-of-state or out ofthe country. + Thereby certiy that I wil fulfil my obligation to fpport abuse or neglect of children pursuant to G..€. 119, sec. 1A. or ce eel b ation on this form and Form 15A ts true. ae, O 28,23 Commonwealth of Massachusetts Board of Registration in Mel ‘Ten West Street, 3rd Flor, Boston, MA O21) (617) 727-3086, ex. 320 Physician Registration Renewal Applicatio wJ98 Before proceeding, please read the instruction booklet. * Copy this form and all atachiments for your own records; you will need copies fr credentialing and other purposes. ‘The Board will charge a fee for exch copy. + Remit $250.00 for renewal fee, + Add late fee of $25.00, if necessary. + Return renewal application in GREEN envelope. + Enclose check with coupon in BLUE envelope, [Retiring (see instructions) OAT Hy sie Registration No: 42863 Renewal Date: 41/96/97 1. Activity Status: clive (Check only one) “Inactive *(see below) —_E} Do not wish to renew 2, Other Name(s), ifany, under which you were licensed: 3. A) mailing/Home Address: CATHRYN L SAMPLES, M.D. 5) Business Address: MARTHA ELIOT HEALTE CTR 75 BICKFORD STREET JAMAICA PLAIN, MA 02130-1402 Home Phone: Business Phone: (617) 971-2100 4. A) Date of Birth 2) Sex B) Lic. Isue Date: 9 4.4 779 D)SS# 5. A) Name of Medical School: Tulane University School of Medicine B) Year Graduated: 73 C) Degree: 6. Specialty Code(s) (See Table 1) Code(s) Hours per Week in Mass. PD 5 Pediatrics ADA 30 Adolescent Medicine 7. Current American Board of Medical Specialties Certification (See Table 2) Code: pe Code 8. Drug License Numbers, ifany: A) Federal (DEA): B) Massachusetts: 9, A) Other states where you are now licensed to practice ‘Abbr: B) States where you previously were licensed to practice Abbr: NY CT CA Corrections (ype or print) (Other Name(s) Mailing Address: City/Town: Zip: (Other Address: City/Town: Homer . Business: C_* ) Date of Birth (M/D/Y): Lic. Issue Date (M/D/Y} Full Name of Medical Schoo: Year Graduated: Degree(MD/DO): Hours Per Week in Mass, FOS, Print Specialty: __ Code: [Federal (DEA): Mass: SSS SSS Abbr: Abbr: “If requesting Inactive status, you agree not to practice medicine, including writing preseriptions, in Massachusetts PRINT NAME AND NUMBER: Last Name: Registration Number:_Y 2863 the credentialing process forthe provision of patient care, Supply the codes from [able 3 and place a check mark nent o those health cre fecilites where you have admiting privileges (AP). o Faslty Cove: {39 / (AP) Pasipy Codes /--(AP) Facility Code, Facility Code: /_{AP) , Facility Code: 1599, print nan 2. Adaional heath cae facilities ot which you previ held preg ot with which you were aso in the past two (2) yeas (See Table 3) Facility Code Pecilty Code 16999, write Name(s) — 1, My medical malpractice insurance is covered by a) ~~ fpsurance Carrier Name of tasuer CO ALCO Alternatively, indicate as follows: 1 am registering wi Please explain exception: 12. Are you currently in a postgraduate training program in = 13. A. Whats your prncipl work sting? (See Table 4) 'B. Core of patients in Massachusets (see instruction boo 1) Average weekly hours involved in 9) 4 2) What isthe approximate percentage of your pate 0, tent cure / B hesiwk —b) inpatient care SR_brsivk eare hours in primary care? ZO % 14, CLAIMS MADE: Has any mocicsl malpractice claim bedo made npsins! you that has not yet been finally setled or ‘adjudicated, whether or nota lawsuit was filed i relation the clam? 15. CLAIMS RESOLVED: Has ny medical malpractice chim tha hs boon made aginst you been settled, adjudicted, o ‘otherwise resolved, whether or nots lawsuit was led in ration fo he claim? 56, Has any tawsuit, other than a medica! malpractice suit, wife i elated to your eompetency to practice medicine, or yout professional conduct inthe practice of medicine, been filed against you or ben settled, adjudicated or otherwise resolved? 17. Have you been charged with any criminal offense, other tHpn « minor trafic violation? 18, Have you been formally charged with or disciplined for af violation ofthe rales, byclaws or standards of practice of aay ‘overnmenial authority, health care failiy, group practied or profesional sacety ot association’? 19. Has your privilege to possess, dispense or prescribe contrfied substances been surrendered 10 or suspended, revoked, denied or restrited by any’ state or federal agency? 20, Have you withdrawn an application for a medics! license 4 21, Has any profesional ability insurance provide rest ‘been dened a medical eense for any renson? limited, terminated, imposed a surcharge or co-peyment, of placed any condition related to professional competency of conduct on your coverage or have you voluntrly restricted, limited oF terminated your insurance coverage in responseto an inquiry by a professionel laity insure provider? 22, Have you completed your CME requirements preceding ypur renewal date (see instruction booklet)? Dy Waiver oquesied —(valver form due 30 ays peor to df o cease expetion), ). Tiinng Progen exemption uur CMEs with your renewal application, BOARD OF REGISTRATION IN MEDICINE SEE REVERSE S10 JOUAEMecUinéo To coupere Tae ques. reuweersreeet sag «ERPs comer ne ov sostowiaseachuserrscen: SB. [:_.)_ TEMS eR NeWat areiGaTioN roe, ‘Soran eilntae Sots aes PLEASE USE THE ENCLOSED RETURN ENVETOPE aR sa 7 a peer tiptoe Te REGISTRATION AMOUNT NOTE! aio ‘erunnen witm a $109 PAY. ie OTe seeeieeice dia wo Ps Taxes [$100 Sears se : ee sae ears vensesnee nen coven cucu eee veumarnao ng gamicrommcscenwmmigromyonewoutio | \Pistnane — CATHRYOY lL Stindes coaead ai Mea wool 2090] enon i + comey na wscen srctcctns: Msi Og owectsrassaun: Mey AGS 1. Amorcan Spaciay Boars Conttoa? TSH (Cheek ityen.) Whien Boar 2 1. Pisce Speciayieny: Peed £ 1. Principal work ete Home addr : 10 Principal busraeeadarse 1 tall nop at wri you hava cunt tect prvieges: 14 Lstat peep at whch you have ola privlgas i the pst 20 yar: 1 Staton othr than Matsachunte in which you ar pve Scanaad to pach: 14. Lstany other states where you ware pravcuty leans o pace: sty nth is Yrs (wheter ey no a MWe was Hedin reabon fo he ole? {8 Has any mecical maoractcn cen boon {6 Have you, a any tne, basa datodant nary crime! proceaaing ower tan mir tate ene? SS aa ee eg ae a I egret arly wi arena tae 18_Have you eer wibérawn 9 apelin lor mosaic or been doe a radial icaee for any reason? 28. Have you evr hed ary menial ness whlch has impure your ably to practica macicne oto function aka student of meicng? te funcion 2 a ueent of medi? 21, avo you ever hed anova nes mien singed your abiey to precios medicine £2, Jew you now, oF have you bow fate pa apenas upon eeohal or eruge? 4 13. Hove you ever fr any season, os Ararcan Specialy Board Caritention? 3B Have you Bee dared recnilicaton by ose cris specally Board? Tovar J 2 in conona ny CE utr sa an enrgcnbe woes now noms LIBS = ZBI? Cae E= 03,5 he 28. amanactoe Bl icon [) eto (hee One | HEREBY CERTIFY UNDER THE PENALTY OF PERJURY THAT AL INFORMATION ON THES FORM (FAONT AND BACK) INCLUDING ATTACHED SHEETS 16 TRUE GURSUANT 70 OHAPTER 47 OF THE ACTS OF 19051 WiLL NOT CHARGE TO OR COLLECT FROM A MEDICARE BENEFICIARY MORE THAN THE MEDICARE REASON. ABLE CHARGE FOR NY SERIES” PURSUANT TO MAL. #20, § 484, CERTIEY UNDER THE PENALTIES OF PERJURY. THAT 1 70 MY BEST KNOWLEQGE AND, BETURNS AND PAISALL'stafe TAXES REGUIRED UNDEN LAW. PLEASE NOTE: ThHG APPLIES EWEN BSVOU REE OU (Gee Rovere Bide) ‘Commonwesth of Nastachusetis Board of Roglstration in Medicine “Ten West Sueet. ord Floor, Boston Massachusetts 02111 1080-1081 Physician Regisuation Renawal Appleaton, Page tot2 — Q2O37L Pegitaton he. ramos Smee S on 16) tar ana, at you ar cee nd: 2) deus ah 2) adaungomay radio amor a Oi cle acd re ie a Es)Tehstone Bate ULL) SAA~S3LC como 2) Tepe (rae) Ops ( i ‘3. of rth O/ONYRE. Sec MALE FeMALE_X 8 Soci Seoutty No. Kone), ‘9 ison Se cnt era 1D. Ln iw: soivewcndane {73 sejoeom io X 00 Ss e.coeny USI Conaca Cote te (Se Tao}: 60,4 ae 1 Sig (ee a cca Paranhos Tn toto! 10 = 18 Mile foe X_taFaineshin/ew Macon x sscine th 2 rt ath Car SSenerarg one > “10 Fay _* 15 Esato atvton sata Secu » sorenmertFasty (amen/carme Sescy esa * 2°: oteson Avy (tee area Faents Poe Tn 1b) as mae ae 10 Resident oc Fetow _ z0Pnctoe ivahing Over Pasent Cure BO = {hee yor wal crite) promnarave octet “30% Ohad Teching * eworesy. BL oun Boswen B80 * spac om Sn Ta PA) _prcen ortin rm, SOX Sucy Cot EL Porat Pace Tin ED) OS pele 10-2) zv you smarionn Specialy Board Ceruee? (77) P10. B}YES, cel wich Boar: 41 Serdar feng Banmunnogy «RMB of ur Masi PS Soudot Pe Sevan aut aeons (0 Bow Oban &Gyecclogy FAA Goat Prat Mean (ks BrersotCoton stl Sugary OF Baud Oprnaraogy PN Sead of apt ogy D Geadol Demag 05 Beadat Strap Suery Songer racceay EM Botdel serene one OF Beasal Oeanrosiar S$ Bon ot suger FP Erosot amy Pac PA Bansal aeiony 13 Bowest Tore Stan, Sard ote eione ‘aut Pesos U) bewest spy NS Geeset heute Span, ‘Bowden htiinion "renee oa ae et pgs aC Fein with a tn Pro Pa Tae ree) mow 3¢ a . ty * rope iad —s rome 3 ree vis wis Naret_ - ai tn "pate esi ee ag pagers FG sw whan me ‘oye Fron Cane 7] ae Feat Cae 10a wt Nae: From cose “ty ery at Hragnsng ACTIVE ea, ot reses meee In aseachutet. Parmanto MLL 7s, Lv net eharg tor eda rm 4 Madonebaatey mara fh the Madcarereusonbi bape my aes. ‘Rm Gane ete as a et a ares ‘hereby arty unde he penaie of pu a al lomo eo stash nner woe owl ‘ran Mastachotetts Bosrd of Registration fh Medicine 1969-1001 Renewal Application, Page 2 032 ‘inane ad ourber. Pryscan asinare:_Si Reginration wo: 4I3 63 12. Q0ruSustweyouueronteemstenncie ited 2 b Sates wher yousrerowaivweretcensed nensice wort WY CT CA ~ _ voweX —“WHCTNE__ GACT rar oes 60 reek ‘lm apt beregitred win flonng wa: gt comers foe ‘4. nae comms ny CME qa th os cmegery talghn,caegsy 8 2 ‘wane Racor 16.2) My ria macs insane re ease ee Eee tae am agng win ACT SOTRWOUED NOMEET DRC PATIENT CARE 6) Pact tn Tein Maneachunts: | 0% ascios 15 tei 7 rts gat urea ony Cok 15. ras ey paragon mel mayracten ce Dan mie i hv you enna aarti any ping ram cei 17 any oa cist gn pring ebay ry bgetrenkt afte ean ‘atonal te ost z 15,101 poi dt on Form 8A stood useing 2¢ mir te est Bu ony. oc wt YES or NO ot) Bh amttn, Pe site atsacton, Yee Ba "Sarda sel San marhSS yaaa oor rakes nga gs aren. Nano ‘nn ysthemen ep ade ow bef ee nn ayer nn 25M jou many rari ion whi ha rg jer ay pace mde ate ion a ae lm 2. Sv you an xr ae wich as roe ou aly praca cto aon aaah of la en 22 yous orb youbaen nt. depart pon 23 ae yout any ol Ales Spay Boa Ca 24 He you ben cris crieetn by ow emo sec Commonwealth of Massachusetts Board of Registration in Medicine » S60 Harrison Avenue, Suite #G-4, Boston, MA. 02118 — (617) 654-9810 http://www.massmedboard.org vf ra Physician Registration Renewal Application fe Before proceeding, please read the instruction booklet. Copy ths form and all attachments for your own records; you will ‘need coples for credentialing and other purposes. This completed renewal form with attachments must be returned in the ‘g7een envelope gt least 4 weeks before your renewal date, ‘Remit $400.00 for renewal fee (non-refundable). + Return renewal application in GREEN envelope. Please review carefully the following information for accuracy and completeness. Make any corrections or alterations as required. All questions must be answered or your renewal will be delayed. 1. Curent Status: Active Registration No.:42663 Renewal Dete:11/06/2003 Ifyou want to change your current status, please check one ofthe following boxes to indicate your new tatu: (Check only one) Dative CDRetiring (se instructions) Cliinactive (see instructions) Cio not wish to renew 2. Other Name(s), ifany, under which you were licensed: ease mabe corrections (pring A) Maing asiness Ty Other Name(s) TL] Name Charge (ener name below) 3.” CATHRYN L SAMPLES Malling Adaress: 0 CityrTown: Se CT 20 2003 Iaip Country, B) Home Address: Business Address CA ciy/Town: Pasta wy Stale: Zip: OZ VS” P Bananas Tokpbons (B/D) SPEES TET fone 3 CityrTown: 5 Home Phone: zipe County: clade Home Telephone Business Phone: |ELEASE NOTE: Only one address can bea P.O. box. The mailing address cannot be a P.O. Box. 4. 8) Date of Binh bSen OP 7. Current American Board of Medical Specialties Certification (See Table) me Code: PE Code: PEO ‘8.Dmg License Numbers, if»m= 5. a} Nate of Medica! School: iD raceme ‘Tulane University School of Medicine 9 : bbs tide ciel 9. a) Other states where you are now licensed to practice (Abbr.) 6. Specialty Code(s) (‘See Table 1) }, ‘Hawnpor Week in 1) Stats Where you wepg previously Hesnsed (Abbr) ADA 0 Adolescent Medicine —— 10, List all current healthcare facilites at which you are efiiated or have completed the credentialing process forthe provision of patient ate. (Supply the codes from Table and plece check mark next to those health care facilities where you have admating privileges (AP), Next to each facility, write the approximate percentage of patient care hours that you provide in exch facility) No affiations, pape g-gn 1999, print nar PRINT YOUR LAST NAME, 2S ices vunaen, 42863 11, My medical malpractice insurance is covered by RJ Insurance Carries Late of Ces, fp 12[3t(03, Insurer's name, (Required):_C R ACO Policy dates: From: —=]—-fo= "ly Pomel) Alternatively, indicate as follows: { am registering with Active status but I am not covered by medical malpractie insurance CT 7-3y ‘because Iam: Check One: [] Not involved in direot/indirect patient care in Massachusetts [] A government employee. Cottervse exempt Pleas explain exemption: _ Sorter 12, What is your principal work eeting? (See Table) _/" (Ifyou are afilited with a healthcare fuciity or eredentialed for the provision of patient care you must complete Question #10 on page 1 and list your affiliations. 13, Care of patiens in Massachusetts (sbe instruction booklet). 1) Average weekly hours involyed in: A) inpatient care _[/ nrsiwk —B) outpatient core GU) hrs/wk ge of your patient care hours in primary care? 2 % M4, + Has eny medical malpractice claim been made against you that has not yet been finally eeted or adjudicated, whether or nots lawauit was filed in elation to the cai? . Hias any medical malpractice caim that has ben made against you been setled, adjudicated, or otherwise resolved, whether or not «lawsuit was filed in relation tothe claim? 16, Has any laweut, other than a medical malpractice suit, which is related to your competency to practice medicine, ‘oF your profesional conduct in the practice of medicine, been filed against you or been settled, adjudicated or otherwise reselved? ] 17, Haye you been charged with any eriminal offense? 18, Have you been charged with or for any violation of laws rales, by-laws or standards of practice of ‘ny governments} authority, health ¢are facility, group practive or professional society or association? 19, Has your privilege to possess, dispehse or prescribe controlled substances been suspended, revoked, denied, reatrcted by, or surrendered to any state or federal agency? 20, Have you withdrawn an application fora medical license or been denied « madical license for eny reeson? provider restricted, limited, terminated, imposed a surcharge or related to professional competency ar conduct on your covertge, or have {terminated your insurance coverage in response to an inquiry by 8 22, CME CERTIFICATION, Have ypu completed your CME requirements preceding your renewal date? TSK Yes L] No Dy CME Weiver. OME waiver form must be submited a est 20 day pia o license expiaton dts. CMEEXEMPTION: Checkong:| (1) inactive stars []_Resideney/Fellowship training (See instructions). ‘See Instructions for CME walver or exemptions, Do not submit documentation of your CMEs with application, © Pursuant to G.L. c. 112, See 1 understand my obligations to report abuse or neglect of children under G.L, ¢. 119, Sec, SIA and the punishment for failure tb comply, * Pursuant to G.L, 6, 112, Sec. 2, ‘will not charge to or collect from a Medicare beneficiery more than the Medicare fee schedule sme, that T have complied with all Jaws of the Commonwealth related 1 the filing of © Pursuant 0 G.L. ¢, 62C, 49A, I cer Massachusetts state tax returns and payment ofall Massachuserts state taxes; reporting of employees and contractors under id remitting child support pursuant to G.L. c, 119A. (See instructions). Gite del withg spinon spac sie __ (GA Gp SICK AND INCLUDE TAR MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. Massachusetts Physician Renewal Application Physician Name: CATHRYN L SAMPLES License No! 42863 PART A 1) Current Status: Active Renewal Due Date: 10/09/2005 Birth Date: Ifyou want to change your current status, please check gne of the following boxes to indicate your new status: (Check only one), (See Renewal Instructions, page 3.) Active © Retiring 1 inactive Do not wish to renew 2) Addresses & Contact Information. Please confirm your addresses and make changes, if necessary. You are rare ny heard of ghana wt ys ofany change of address. Home and Business address CANNOT bea Past Office Bor. Gnas 2a)MAILING ADDRESS! , = : cy: | Malling Address oct 11 ac[M CingrFoyme sue jeter ~ : County: 1 Cnc re tachnge asp oid 2) HOME ADDRESS sue: 3: ‘County ee Home Telephone: ct ee change ads Home edaress camel be a Post Office Box 25) BUSINESS ADDRESS Business Address 300 Longwood Avenue - 10306 City/Town: site: Boston, MA 02115 “a are Business Telephone ( Phone: (617)355-5767 i Check hve change this adress ‘Business address cannot be a Post Office Bor 3) E-mail Address: 4)FaxNomber: __b( 9 = “2.20 <0 s@e~ 5) Specialties (See Renewal Instructions, page 4) Delete? | Additional specialties: Pediatrics o ‘Adolescent Medi a o {©) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information (Gee enclosed instructions and Renewal Instructions, nage 4.) List Certifying Board(@) below: Update General Certificates and Subspecialty Certificates Delow. Please add additional Certifications as required. Bord Name ABMS or AQA| Certifcate/Subspeciaty Correct? _Delete? Pediatrics ‘ABMS _ | Pediatrics ee) Pedianics ‘ABMS _ | Pediatics Adolescent Medicine 6 oO c a o oo Page 1 of 5 18 gO-eIOL 192 : Massachusetts Physician Renewal Application Physician Name: CATHRYN L SAMPLES License No 42863 (See Renewal Instructions, page 4) ‘Please make corrections as necessary 7) Drug License Numbers, if amy 8a) Other states where you are now licensed to practice (Abbr.) 2) Massachusetts: ae ») Federal (DEA): 8b) States where you were previously licensed (Abbr.) «) Federal (DEA) XS: NY CT CA 9) What is your principal work setting? (Sce Renewal Insiructions, page 4,) Principal Work Seting: Hospital Change Please enter the approximate number of work hours at your principal work setting: SO. 10) List all current health care facilities where you are affliated or have completed the credentialing process for the provision of patient care. (Supply the name of the health care facility from Reference Table 5 on Page 16 of the Instruction booklet). Next to exch facility, write your staff category at that facility (Admitting, Active, Courtesy, Associate or Consulting), and the approximate number of hours of patient care that you provide at that facility. Include any affiliations with on-line preseribing services or companies, Please provide all information for additional {facilities on a separate sheet, if necessary. No Affiliations ( Please enter the approximate number of work hours for each Heslth Care Facility below: Heath Gare Fity ve Ronen traction page) [Dawe] come OR | RE Cir Hp fading =o] ini rm Other a [=] a o 0 11) Care of patients in Massachusetts (See Renewal Insiructions, page 4) Average weekly hours involved in: 2) inpatient care © _4 _ hirswk Change to: _47/_ hrs/wk by outpatient care _20_ hrs/wk Change to: _{ 4 hrs/wk 12) Medical Liability Insurance Information (See Renewal Insiructions, page 5) My medical liability insurance is provided through: (check one) Bl Insurance Carrier (complete below) ‘Curent Insurance Carrer: CRICO Change to: Policy dates: From O// Of) 2005° To #Z/ 31/2005" (required) 1G Letter of Credit subject to Board approval (attach « copy) C 1am registering with Active status but I am not required (o have medical liability insurance because J am: Cheek one: D Not involved with direct or indirect patient care in Massachusetts C1 Government Employee Federal Tort Claims Act (FTCA) 1 Otherwise exempt (Please explain): Page 2 of 5 1S SO-Z101 Massachusetts Physician Renewal Application Physician Name: CATHRYN L SAMPLES License No: 42863 13) Do you perform any surgery in your office? (See Renewal Instructions, page 5) Yes No if Yes, please complete Form PCA-O "Office Based Surgery” In questions 14-21, the phrase "time period” refers to the following: all time from the day you signed your last license renewal/application, to the day you sign this renewal application, inclusive, (See Renewal instructions, page $) ‘You most check either YES or NO to each question. Provide details on FoR if you answer “YES” to any questions. Refer to ‘Renewal Instructions for additional information and definitions. ALL. questions in this section must be answered, YES _NO 10 CLAIMS MADE T 2) New: Has any medical malpractice claim been made aginst you daring his tine period, whether or ‘not a lawsuit was filed on that claim? +b) Pending: Are there any unresolved malpractice claims against you today, any claims that have not been finaly sted or inal edjcatee? 15) CLAIMS PAID Has any medical malpractice claim ngninst you (whether o not Tawst was ed on tat lim) ben rested, setled,o adjudicated uring this tine period? 16) OTHER CIVIL LAWSUITS Question 16 refers to claims o ston relate to your competency to practice medicine or your ‘Profesional conduct nthe pracize of medicine, 4) New: Have there been any lavas, other han medical malpractice las, been filed against you

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