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    George Topulos Massachusetts License Applications

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    GEORGE TOPULOS MASSACHUSETTS LICENSE APPLICATIONS

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    George Topulos Massachusetts License Applications

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    GEORGE TOPULOS MASSACHUSETTS LICENSE APPLICATIONS

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    GEORGE TOPULOS MASSACHUSETTS LICENSE APPLICATIONS

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    GEORGE TOPULOS MASSACHUSETTS LICENSE APPLICATIONS

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    Download as pdf
    151 views54 pages

    George Topulos Massachusetts License Applications

    Uploaded by

    8453210
    GEORGE TOPULOS MASSACHUSETTS LICENSE APPLICATIONS

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    © All Rights Reserved
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    Commonwealth of Massachusétts Board of Registration in . 3 ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086 Tupivww-massmedboard.org Before proceeding, need copies for credentialing and otber pu greenenvelope 4 weeks before your renew + Remit $250.00 for renewal fee. + Add late fee of $25.00, if necessa Please review carefully the follow alterations as required. 1, Current Status: Registration No.:59937 7 chments for your own records: you will form with, steer aust ae wa the v CUAGT ira reneveal application In GREEN envelope. lose cheek with coupon in BLUE envelope. |and completeness. Make any corrections or Renewal Date: 97247001 ‘you want to change your eurrent status, please check one of the following boxes to indicate your mew stamus: (Check only one) Diactive CD) Retiring (see instructions) 2. Other Name(s), ifany, under which you were licensed: 3. A) Mailing/Business Address: GEORGE P TOPULOS. 75 FRANCIS STREET DEPARTMENT OF ANESTIIESIA BOSTON, MA 02115-6110 B) Home Address: Houne Phone: Business Pow: 4). 7ZA~ BAIF Di inactive (see instructions) TDo not wish to renew Please make corrections (type or print) [Other Name(s): Mailing Address: CityrTown: Sa Cxyrtown:— Sie eee cy Eee Baniness Tipe ome Address: City/Town: Zip: Coury Home Telephone x [PLEASE NOTE: No P.O. Box addresses for home or business addresses. 4, 2) Date of Birth: by Sex: M esse: 5. a) Name of Medical School: ibgalMesicuses Meal Scho! 1980 6. Specialty Code(s) (See Table 1) Codels) Hours per Week in Mass AN 0 9. by year: Anesthesiology 7, Current American Board of Medical Specialties Certification (See Table 2) “ACode: Code: 8. Drug Licease Numbers, if any: a) Federal (DEA): b) Massachusens: 9. a) Other states where you are now licensed to practice (Abbr) b) States where you were previously licensed (Abbr) 10. Current health care facilites at which you have completed the credentialing process for the provision of patient care. (Supply the codes from Table 3 and place a check mark next to those health eare facilities where you have admitting privileges (AP). Next to cach facility, write the approximate percentage of patient care hous that you provide in each facility) Facility Code: 23.5." (AP) $= % Facility Code: 1999, print néme(sh code: ¥ RL! Har) IS % Factey Code /_(AP)__% Facility Code: (WP) % (AP) —% Fcity Code: — ar) PRINTYoURLasTNAME: TOPVIOS _- LICENSE NUMBE! cae : 11. My medical malpractice insurance is coyered by a) PX Insurance Carrier b) 1) Letter of Credit Name oftasmer__C RICO. Alternatively, indicate as follows 1am registering with Active status but [ am not covered by medical malpractice insurence because I am (check one) 2) CNet involved in direcvindirect patieat care in Massachuserts b) [1] Otherwise exempt Please explain exemption: 12, Are you currently in» post-graduate taining program in Massachusers a a resident or clinical fellow? (check one) [) Yes [No 13. A. Whats your principal work sering? (See Table 4) _/ 2. B. Care of patients in Massachusetts (see instruction booklet), 1) Average weekly hours involved in: 8) outpatient care Inrsiwk b) inpatient care __hrs/wic 2) What is the approximate percentage of your patient care hours in primary care? _()_% = QUESTIONS REFER, P, ‘WO (2) ¥1 14, CLAIMS MADE: Has any medical malpractice claim been made against you that has not yet been finally sefled or adjudicated, whether or not «lawsuit was filed in relation to the claim? ' 15, CLAIMS RESOLVED: Has any medical malpractice claim that has been made against you been settled, adjudicated, or otherwise resolved, whether or not o lawsuit was filed in relation tothe claim? 16. Has any lawsuit other than a medical malpeactice suit, whichis related to your competency to practice medicine, ‘or your professional conduct in the practice of medicine, been filed agunst you or becn settled, adjudicated or otherwise resolved? 17. Have you been charged with any criminal offense, other than a minor trafic violation? 18, Have you been charged with o disciplined for any violation of laws, rules, by-laws or standards of practice of ny governmental authority, heath cre facility, group practice or professional society of association? 19, Has your privilege to possess, dispense or prescribe controlled substances beea suspended, revoked, denied, resticted by, or surrendered to any state or federal agency? 20. Have you withdrawn an application fora medieal license or been denied a medica license for any eason? 21. Has any profesional 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 restricted, limited or terminated your insurance coverage in response fo an inquiry by & professional liability insurance provider? 22, CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date? Bd Yes [1] No 01 CME Waiver requested (CME waiver form due 30 days prior to date of license expitation) Chemeeremption — | ‘See Instructions for CME requirements. Do not submit documentation of your CMESs with your renewal application, Pursuant to GL. €.112,§ 2, Iwi nt charge oor collect froma Medicare Deneficary more than the Medicare fe schedule amount. Pursuant fo GL. ¢,62C, § 49A, (0 thebestof my knowledge and belie, {have filed al Massachusetts state fax reterus and pad ll ‘Massachusetts sate taxes tbat are required under lav. NOTE: This applies even Ifyou reside out-of-state or out of the United States. + Pursuant 0 G.L &. 62C, §47A, tothe best of my knowledge and belief, Iam in compliance with M.G.H.C. 1194 relating 10 withholding and remitting Child Support. + Pursuant to GL. € 112,514, Iwill full my obligation to report abuse or nepec of children ax required by GL. «119, tA. + Thereby certify under the penalties of perjury that all the information on the Renewal Applicesion and Form R is rue, Signature: Heaigd Talon dae 130/04 x MUST. ND INCL wy, ie ing, of any change of as MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. 2 ~ Commonwealth of Massachusetts Board of Registration in Medicine’ ‘Tea West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086 wea hetpilwew massmedboard.org Physician Registration Renewal Application Betore proceeding, need copies for evedentating und other purposes, Ti “i stcen envelope 4 weeks betore your renewal d + Reratt $250.00 for renewal foe. + Ad ate Fee of $25.00, If necessary. Please review carefully the following i alterations as required. 1. Current Stoms: Active If you ws lactive Retiring (soe invctions) 2. Other Name(s), if any, under which you were Neensed: 2. A) MailingyBusiness Addcess: GEORGE P TOPULOS 175 FRANCIS STREET DEPARTMENT OF ANESTHESIA, BOSTON, MA 02115-6110 18) Honte Address Home Phone BusnessPhone p33 ZA ~ BRIT Registration No.59957 to change your curven status, please check ang of the following boxes to indicate your new status: (Check only ane) Renewal Date: g724700 ‘Clinactive (see instructions) De nor wish to renew Please make corrections (type oF print) [omec Nameley Malling Adress: City/Town: ip: ‘Counuy: you wilt, i with attachments must be returned in the inane Adon City/Town: ip: ~ County usineis Telephone 2) 4, 9) Date of Binh: by Sexi M 2) 834 5, nano St serach ‘ oy mieten ta eon 6 Sei Coe Tate Sn ere ied nen, AN 0 Anesthesiology “0 10. Curreut bealdh cae f [ftome Adare City/Town: Sine Zip: ‘Coonmry: |Home Telephone: 2 PLEASE NOTE: No P.O. Box addresses for howe or business addresses. — 7. Current American Donsd of Medical Specialties Certfieation (See Table?) ‘ACode: Code 8. Drug License Numbers, ifany: ‘a) Pederal (DEA): 'b) Magsachusets: 9. 2) Other etatet where you are now licensed to practice (ADDL) b) States where you were previously licensed (Abb) ies wt which you have completed the credentialing process forthe provision of paient care. (Supply the codes from Table } and place a check mark next o those Neath care facilites where you have adiniting privileges (AB). [Next 9 each foci, write the approximate percentage of patient care hours that you provide in exch fciity), Facility Code: ¥ A. ae (ae) IS % Facilcy Code:___/_(AP)__% Facility Codes, (AP) _t% Facility Code (Aey_$— % Paciliy Code: 7 (AP) __% Feeilty Codes") (ae) 1999, print me i PRINT YOURLASFNAME: TOPUWJOS ie LICENSE NuMBER: £7 9.9 | ot insurence is covered by a} Dif surance Carrie &) ‘E] eter of Credit Name oftmuer _C RELO i Alternatively, indicate as follows: wy tne ith Atv stats bt an a coed hy cl walposiz umes Sores Fas ee ny 9 Not involved in dnecindseetpatat cae in Masschusets ») [] Cteruae event Please explain exemption: 1a a wnat na Festgdase ting ropa in Michael oli alod? (hak oo) CTV TB 1A. What is your principel work setting? (See Table 4) _/_ Qa '. Care of patient in Massachuseis (se instruction bookie), Fis UD Average weekly hour involved in: a) utpatienteare _S7 alk by inpatient care QOD besnk 2) a te eon pegs of you pti ee us inp ce? @) [ves No 4. seedy medical malpractice cairo been made xgsinst you tha as nt yet been finally sctled or adjudicated, whether or not a laweuit was (ed in selation fs the eons Is. eeat ay mesical malpractice clu that has been made aguinst you been seed, ‘ijleated, or oerwite cesolved, whether or nota awa was fled in lain to aceon 16. Hes any laweuit other than a medical malpcactice suit, which is related to your competency to practice medicine, other ec esa! Conduet nthe practice of mein, been ied agis pu or Been ste ‘adjudicated o 17; Have you been charged with any crisanal offense, other than a muinr ratte violation? 18 Have you been charged wit or disciplined fr any violation of laws, ules, by-tawe oe standards of practice of pe Rotemmentat authority, health cane facility, group practic or rotewional anciely ev aemcurnee 1 Baa your Piles to panes, dispense or prescribe controled substuases been suspended, revoked, denied, restricted by, or surrendered to any tate or federal agency? 30 Have you withdrawn an application fora medical license or Been denied a medical license for any reasou? 21. Has any profesional ably insurance provide resuicted, limited, termined, imposed a surcharge or 2 GMECERTIFICATION: Have you completed your CME rouicemnspresuling you renewal Jae? Bre O no C1 CME Waiver requested (CML waiver fm due 30 days prior to dae of license expiration) CleME exemption «| Sez Instructions for CME requirements. Do ot aubmié documentation of your CME mtn Your renowal apputeation, | ie or collec from a Meulare beneficiary more thas te Medicare fe schedate amonet, pata ait Usited Stats. © Tincnts Gd, S S26, § £74, thebestof my knowledge ond bell, Lam compliance with MGC. 119A retaing to withholding and remitdng Chitd Support 1 Panant tC. 6.112 814, Ei tay eBigetion repr abuse or neglect of chiéren ar required by Gib 6 119.8 5tA, © There covily unter the penalis of perjury that et the infrmatton on the Renewal Atptoaton oad han, R iserue. Signatone: Use go IG | Dau: © 130) XQUMUST SIGN AND INCLUDE PART B, WITH YOUR RENEWAL APPLICATION Be ie. che ire Meant Rectations teoute that en nls the Board in weld. of any change of eres MAKE A COPY OF YOUR APPLICATION AND ALL SUTACHMENTS BEFORE MAILING, 80°d VOO'ON Z¢:0T 10.80 Nhe. B629z94)Ta:AT HTeauy eKine wn 1807 1 UP REGIS INA LIU IN MEDICINE 100 CAMBRIDGE STREET BOSTON, MASSACHUSETTS 02202 RENEWAL APPLICATION ‘986-1988, REFN at A Be | ue oN You MUST SIGN BELOW ci Par TAS wncaea] care ree aa Ems —]_B0ol | oe wo | | 50937 | 100.00 ae eee | 8 ceorce p topuas $2 75 FRANCIS STREET 34 DEPT ANESTHESIA 8% BOSTON MA 02115 SE WATE BETO ETRE SEE REVERSE SIDE YOU ARE REQUIRED TO COMPLETE THE QUESTIONS ON THE ALYEREE SIDE OF THIS APPLICATION (SEE {TH ENCLOSED INSTRUCTIONS FOR OETAILS| IF YOU ANSWERED “YES" TO ANY OF THESE QUES- “HONS. YOUMUSY CHECK THIS BOK PASC USETHEENGLOSEDRESURUENYELOFE NOTE MD cee Sotho oat REFERRED. PERSONAL CHECKS. ARE Dy ROCEPTARCE, 3500600509372 011586 10000000004 von none FCO0G2 fered TEPUOS oan o om vcsst cron UMass io eran, LAI LD con. 2. Puncipat wore sing, LOSI d 4 riopatcee tens Saaree a5 FEOUT Stutatonmtsrnesyavrmeciertattepiiige GiblamPesortene Het P deipiia>,; Norulceh NsihAe ORL - Peo oS 6 Stites ner than Mataachutets in whic yOu are lcosed to practice 1. Puncival Seacste) vt in any malpractice suk comnanced sinc 10:80? 11. Ihave complted my GALE: requirements ween 118/84 4 viSMBes toons ELT ee wat A seacive practioner (Crack Mhentuy century uipén THE PENALTY OF PERJURY THAT THE ABOVE INFORMATION 1S TRUE, Sino [YOUNMUSY ALSO SIGN THE FRONT OF THIS CARD} + Remit $250,00 for renewal fee, + Add late fee of $25.00, if necessary. th 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 atachments for your own records; you will need copies for credentialing and other purposes, ‘Return renewal application in GREEN env + Enclose check with coupon in BLUE envelope Registration No.: 509377 Ifyou want to change your current status, please indicate below: (Check one). Cinactive (see below *) (Active Retting. (see instructions) 2. Other Name(s) if any, under which you were licensed: 3.a) Mailing/Business Address: GEORGE P TOPULOS, M.D. 75 PRANCIS STREET DEPARTMENT OF ANESTHESIA BOSTON, MA 02115-6110 B) Home Address: HomePhone: (ys Business Phone: (617) 732-8217 4. A) Date of Binh: B) SSH 5. A) Name of Medical School: University of Massachusetts Medical Schoo! 8) Year Graduated: 1980 6, Specialty Code(s) (See Table 1) Cadets) i Sex: (©) Deree: 30 aN 50 Anesthesiology 7. Current American Board of Medical Specialties Certification (See Table 2) Code: a, Code: 8. Drug License Numbers, if any: A) Federal (DEA): B) Massachusetts: 9. A) Other states where you are now licensed to practice ‘Abbr: BB) States where you previously were licensed to practice Abbr: Renewal Date: 07/24/1999 1. Curent Stas: Ace: Odo not Please make correetions((ype or (Giher Namal) Malling Address CityTewn: Sia zip: County: {IEOS, Print Specialty: ‘If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts. PRINT NAME AND NUMBER: Last Name:_TOP yO Registration Number. £O.9,3 “F 10. Current health care facilities at which you have completed the credentialing process for the provision of patient care, Supply ~ the codes from Table 3 and place a check mark next to those health care factlitis where you have admitting privileges (AP). Next to cach facility, write the approximate percentage of patient care hours that you provide in each facility. Facility Code: 7A 4) gar) 2S” % Facility Code: 32 ST (AP) $7 % Facility Code___)__(AP)___% Facility Code:___/_(AP)_ % Facility Code: (AP)__% Facility Code: _(AP)____% 1£999, print name(s a - 11, My medical malpractice insurance is covered by a) (X) Insurance Carrier 6) []. Lens of Credit Name oftnurer, EC RECO i Alternatively, indicate a follows: | am registering with Active status but I emt not covered ty medical malpractice insurance beeause Iam (check one) 8) (Not involved in direevindireet patient caren Massachusets b) [[] Otherwise exempt Please explain exemption: 12, Are you curently ina post-graduate training program in Massachusetts asa resident or clinical fellow? (check one) [} Yes Jaf No 13. A. What is your principal work setting? (See Table 4) _/_ 2) B. Care of patients in Messachusets (se instruction booklet) 1) Average weekly hours involved in: a)outpatient care _@_Isfvk b) inpatient care ob) hawk 2) What is the approximate percentage of your patient cate hous in primary care?_€2_% PART A-OUI NS LY TO TI Questions 14h only. YES or ‘details on Form R for all VES wuswers except for question 2._Refer co the Instruction ional information and ‘efiniions, You must answer ALL questions. oF this form wil be returned to you und your license renewal may be delaved [YES NO) 14, CLAIMS MADE: Has any 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 to the claim? 15. CLAIMS RESOLVED: Has any medica! malpractice claim that has been mado against you been settled, ‘adjudicated, or otherwise resolved, whether or nota lawsuit was filed in relation tothe claim? 16, Has any lawsuit, other than a medical malpractice suit, which i related to your competency to practice medicine, ‘or your professional conduct inthe practice of medicine, been filed against you or been seed, adjadleated or ‘otherwise resolved? 17, Have you been charged with any criminal offense, other than a minor trafic violation? ; 18, Have you been formally charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of any governmental authority, health care fcility, group practice or professional society or association? 19. Has your privilege to possess, dispense or prescribe controled substances been surrendered to or suspended, revoked, denied or restricted by any state or federal agency? { 20. Have you withdravn an application for a medical license or been denied a medicel license for any reason? 21, Has any professiona 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 restricted, limited or terminated your insurance coverage in response to an inquiry by a professional liability insurance provider? 22, CME.CERTIFICATION: Have you completed your CME requirements preceding your tenewal date? R(Ves [] No C1 CME Waiver requested (CME waiver form due 30 days prior to date of license expiration) ( CME exemption See lastruetions for CME requirements. Do not submit documentation of your CMEs with your renewal application. + Pursuant fo Glee. 112, 2, willnot charge to or collec from a Medicare beneficiary mare than the Medicare fe schedule amount ‘+ Pursuant fo Gib. 62C, §49A, to the best of my knowledge and belie, {have te all Massachusetts state tax returas and pald all Massachusetts state taxes that are required under law, NOTE: This applies even you reside out-of-state or out of the United States, + Pursuant fo G.L. 112, § 141 will fulfil my obligation to report abuse or neglect of children as required by GL. c, 119, § SIA. + Thereby certify under the penattes of perjury that all the information on the Renewal Application and Form R is true. some B.s.04 05 qe Sy eee owe BIZ ILS YOU MUST SIGN ANDJNCLUDE PART B, WITH YOUR RENEWAL APPLICATION 11489,0000 1, PHYSICIAN INFORMATION GEORGE" i WP. TOPULOS First Name ‘idle ia Yast Nome Sig “Wek age toa Tare seareae ECE Mass License #50997. Firs ssue Date 06/16/88 License Stains. Active filiation 15 Francis St, Brigham & Women’s Hospital Dept Anesthesia Boston, MA 02115-6110 USA (617) 792-8217 Make address corrections here... Make any corrections wo ane here Insurance Plan Affiliation: Licenses Held in Other States: aa Beet Accepting New Patients? Clves (No | ;: Accept Medicaid? = (es | (Please correct as necessary) Hi, EDI Tie University of Massachusetts Medical School MD. 80 z ‘Medical School ‘Degree i Dae ‘Mai earth : ee _. Jind. asides Progr Si End. Residen Progra) Siaré eee ; é cause a ‘Reson: Program(s) Siaré Mil, SPECIALTY BOARD CERTIFICATION Primary Specialty; Anesthesiology ‘Cenifving Board Name: Board of Anesthesiology Secondary’ Specialty Cerifying Board Name: Mate any corrections here: Moke any corrections here: Board of Registration in Medicine Physician Profile 11489,0000 IV. BOAI [PLINE Fira Decisions and orders issued by the Massachusetts Board of Registration in Medicine, Nature Date Board Action NONE ¥. HOSPITAL DISCIPLINE Hospital Date Disciplinary Action NONE VI. CRIMINAL CONVICTIONS ‘The Board of Registration is unable to obtain accurate data for this category ai the present time. This information will be included when the court system is fully computerized. Please list any criminal convictions. Include coaviction date and nature cfeonpiiot : NONE sci VII. MALPRACTICE No.of Years in rectives # Details oceans paidtfordz Toputos «= ONE “3 Due Amount Fed _0,0900 Basis for Complaint Date Anvount Paid Basis for Complaint : 7 Date ‘amount Paid Bass for Complaint "7 Date SS Amount Paid : Basis for Complaint = Date Amount Pa Basis for Complaint aa Date 2 Aaa Past are Basis for Complain | Sate VII! PHYSICIAN HONORS & PEER-REVIEWED PUBLICATIONS 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 Note: Please return the survey in the enclosed envelope to: Atlantic Associates, Inc., 8030 South Willow Street, Manchester, NH 03103 Board of Registration in Medicine Physician Profile Commonwealth of Massachusetts Board of Registration in Medicine i y\ 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 end other purposes. “The Board will charge a fee for exch copy * Remit $250.00 for renewal fet. Return renewal upp! ication in GREEN envelope. + Add late fee of $25.00, if necessery. + Enclose check with coupon in BLUE envelope. Registration No: 50937 Renewal Date: 97/24/97 1 Activity Status: BfActive Retiring. (see instructions) ae {Ceckontyon) “EJ Inactive *(see below) —E] Do not wish to renew : 2. Other Name(s), if any, under which you were license (pe or nt (Other Name(s) eae ances 3. A\Mailing/Business Address: GEORGE P TOPULOS, M.D. Maling Address: — 75 FRANCIS ST CityrTown: Stats: _ DEPT ANESTHESIA ge BOSTON, MA 02115-6110 haat eaten : B) Home Address: [Other Adéres: city/town: Zip Country Home Phone: - Bees aaa —— Business Phone: {617} 732. 8237 Date of Birth (M/D/Y) Sex (MIR ere : ee M Lic. Issue Date (MID/Y): SS#: B) Li, Issue Date: as 06/26/63 Full Name of Medical School: 5, A) Name of Medical Schoo! University of Massachusetts Medical — School By Veer Graduated: gq ©) Degree: agp Year Graduated Degree 6. Specialty Code(s) (See Table 1) (Code(s Hoouts Per Week in Mas. Code(s) Hours per Week in Mass Pees aN 50 Anesthesiology 7. Current American Board of Medical Specialties Certification (See Table 2) Code: a. Code: Drug License Numbers, if any: A) Federal (DEA): B) Massachusetts: ‘A) Other states where you are now licensed to practice Abbr: 'B) States where you previously were licensed to practice ‘Abbr: iF, Prin Specaty Code: Code: Mass: Federal (DEA): Abbr: Abbr: *If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts PRINT NAME AND NUMBER: LastName: TOPULOS Registration Number. SO9S > 10.A. Curent heath care fies t which you have complete the eredemting races forthe provision of paint car. Supply the odes hom be edge ee me et bebe lls ar Yon aang vie (AP) wy Cade) A] KAP) Facity Cole, (AP), aii Code a Fas Cade Can) Facty Ce —L(AP) Fasily Codes —/1a) 1989, prin nl 1, Adéitional health care fa ies at which you previous held privileges or with which you were associated in the pas v0 (2) yeas (See Table 3) Facility Code:___ Facility Code____ Facility Code:____ Facility Code: Facility Code: 1£999, write Name(s): 11, My medical malpractice insurance is covered by ) _% Insurance Carrier _b) Letter of Credit Name of tasirr: © RIC. ‘Alternatively, indicate as follows: 1 am registering with Active stolus but} am not covered by medical malpractice insurance because tam (heck on) 8)___ Not involved in cretindee patent core in Mestacusets b)___Oterise exempt Please explain exemption: 12, Are you curely in a pos-graduat ining program in Mass. asa resident or clinical fellow? (chek on) Ye pve 13, A, What you principal work setting? (See Table 4) B, Care of patients in Massachusts (se instruction book) 1) Average weekly hours involved in: 2) eutpatien care _rs/vie _b) inpationt care SCD besnk 2) What i the approximate percentage of your patient cre hours in primary care ?_@)_ 9% PART A uestions 14 through he past two (2) years only. Check sither VES ot NO (NOT NVA) to enth quettion. Provide 0.2) YEARS: YES NO] 14, CLAIMS MADE: ties ny media maprctiecnim been made ais ou that has no yet been ily seed or : adjudicated, whether or nota lawsuit was fled i relation to the claim? 15. CLAIMS RESOLVED: Has any medical malpractice claim that has been made against you been sete, adjudicated, oF ‘otherwise resolved, whether or nt a lwsult was filed in rlaton tothe claim? 16, Has any lawsuit, other than a medical malpractice suit, which is related 10 your competency fo practice medicine, or your professional conduct inthe practice of medicine, boon filed against you ox been stile, adjudicsted or otherwise resolved? 17, Have you been charged with any criminal offense, other than & minor traffic violation? 18, Have you been formally charged with or disciplined for say violation ofthe rules, by-lews or standards of practice of any _goverimental authority, health care faciliy, group practice or professional socesy or association? 19, Has your privilege to possess, dispense or prescribe controlled substances heen surrendered to or suspended, revoked, denied or restricted by any state or federal agency? 20, ‘ave you withdraven an application for emedical lense or been denied a medical license for any reasoa? 21, Has any professional lability insurance provider restricted, limited, terminated, imposed a surcharge or co-payment, or placed ary condition related to professional competency of conduct on your coverage or have you Voluntarily retricted, limited or terminated your insurance coverage in response to an inquiry by a professional ibility insurance provider? 22. Have you completed your CME requirements preceding your renewal date (se instruction bookley? Cl Weiver requested (Waiver form due 0 days porto date of ficense expiration), ) Tréting Program exemption See Instructions for CME fequirements. Do not submit documentation of your CMEs with your renewal application RENEWAL APPLICATION CONTINUED ON PAGE 3. ALL QUESTIONS ON PART B MUST BE ANSWERED, a STefrloa pub lb 27 ‘Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1995-1997 Physician Registration Renewal Application. Repsuation No, Stas Foe Renewal Date Late Fee _50937 ACTIVE 850097 /24/95 $25.00 CCorfection of Malling Address Malling Address “Aadess (Malin: GEORGE P TOPULOS, M.D. 75 FRANCIS STREET Ciyftow DEPT ANESTHESIA State BOSTON, MA 02115 cae Directions: Before proceeding, please read the instruction booklet, Some questions are options + Future to renew ln a Uinely tanner will esuse your Heenss to lapse and may affect your bility fo practce medicine la the Commonwealth. (See enclosed letter). + Make copy of thls form and all uttachments for your own records - you wil need copies for ‘credentialing end athe purposes. The Board will charge a fee foreach copy i provides, + See instructions on detachable coupon at botiom af this page, Pre-Printed Information Corrections of Pre-Printed Information 1, Other name), ifany, under which you were licensed: 2.Home Addres! Duzof Binh (DIY). LL Sex /:_ Lic, sue Date QH/D/Y): SSH Home: (_) Business: 6/3 2:32- BaF 3, Daw of Bir: Sex: Lic. tusve Dae: 96/16/83 SSF ‘Home Phone ‘Busines Phone Gee aee (617) 732-D35q 4, Name of Meza Scholz University of Massachusetts Medical School, YearGraiuaed:80 Degree: MD 5.) Other sates where you we now nse to practice (Abb): Stes where you peviouly were Hcensed to practice (Abbe): 6 Specialy Cotes (Seo Table: ode _Hours per Week in Mas. AN 50 Anesthesiology 7. Ifyou ae curently American Specialty Board centfied, ener codes: (See Table 2) Code: A Code: 8, Drug license umber) fany: 4) Pederal (DEA) b)Massachusens ‘easeal (DEA) Mast: a ee Ge) + Thereby certify that if requesting Inactive status, I will not practice medicine, Including writing prescriptions, in Massachusetts. PRINTNAME AND NUMBER: PipricintastName TOPUV2OS ___ negisusionambor LOPS 10.) Curent anh care faces) at which you have completed te eredentiing race fo he provision f patient care, Supply the ade rom Table3 ap place check ark next to toe facies whee you have aii privilege (AP) Tasty Cole: Beck D7 Kear) Fay Cole — (AP) Fay Code a) Facility Code: ——— (AP) Peciiy Code: ae AP) Paty Code: (AP) 1£999, pint name(s) 1) Additional hospitals at which you previously held privileges and other health cae facilites with which you were associated in the past? yeu, (SeoTabie 3) Facility Code: LL 4 Facitiy Case: Facility Code: Facifiy Code: Failty Code: ——. 1196, wate name(): 11. My medice) malpractice insurance is covered by (a) Insurance Carrier ZA. (b) Leusr of Crecit, ___ If epplicabe, check one. List newer, RECO ‘Alternatively. indicate as follows: Yam registering with ACTIVE stats, but Iam not covered by medical malpractice insurance because | am (Check One): (i) Not involved in dzectindicet patient eare in Messachuseits: (8) Oterwise exempt ——— State how otherwise exempt 12. Axe you currently in a post-graduate waining program in Mass. asa resident or clinical fellow? Yes __ No 2. (Check one) 13, «) Whatis your principal work suing? See Tables) LD t) Care of patents Masuhazars (Se srt booklet) {) How many hou er ical week ue you corenly volved n oupatoncaeip Mass?) — vk How nary ur pe pial weck we youcureny ivlved nips cre in Mas? aw ) Apponintely what perotage of out peat care hou me a pay cu? (Gevisiusdos for defination of pry cs) * ‘Questions 14 through 24 refer the past two pets oly. Check ier YES ox NO (NOT N/A) ach qzaton. Provide dis on Forms R-1 and R-2 for all YES answers. Refer to the instruction booklet for additional information and definitions, TN THE PAST TWO YEAR: XS NO. \UCCLAIMS MADE: Has any mee malate cin brn made iat you wich as nat yet ee Sly et or sdjudicated, whether or ota lawsuit was filed in reltion io the cli? 18, CLAIMS RESOLVED: Has any medical ape in gas ou bese, ened oer \whesher or not lawsuit was filed in relation to the claim? : 16. as ny wl oer than a media malware aut, whch is elated o your competency to practice malik, 0 You O- tenon nt pref mein, en i pia 08 yan, tee ender owe resolved? . 17. Have you been charged with any ciminal offense, other han a minor afi violate... 1 Fave you ten foal charged wih or icine foray violin of tere, or tana of ace ry povernmental thority, health cave facility, group prectce or professional society or association? 19, Has your privilege to poses, dispense or prescribe controlled substances been surenderad to or suspended, revoked, denied ‘restricted by any sae or federal agen? .. 20. lave you wiheawn wa eplcaon fre medical censor bom ened amin for my reason? . 21. Has any professional silty insurance provide restricted, limited, terminated or imposed surcharge on your coverage or vee volar rice or wine your inane coverage ej tan ity yates libitity surence provide? : 22. Have you been agroved with ro you hae a medial ono wich ini or mp your sity to preci meine? - 3, Have you engaged inthe use of any chemical substance(s) which in any way interfered with your ability to practice? 24, Hove yu volar) motifed or arise ine ous of rate f meine for ay eo hr hana mdi condition? se 25, Thaveconplctad my CME roqrenans in ih wo yeu pocding my encwal dae: Yor 2K No wer oud No, waning program exemption (se instruction booklet). requesting a waiver you mus fl outa seperate Waiver Form. The waiver must be granted by the Board before your Henge wilt be renewed. See instructions for CME requirements. Do not submit documentation of your CMESs with your renewal application, + Pursuant to G.L.c. 112, ce. 2] will not charge to oF collect from a Medicare beneficlary more than the Medicare reasouuble charges. + Pursuant wo GL. . 62 C, sec. 49A, hereby certify wader the pains and penalties of perfury tht, tthe best of my kaowledge and bole, [ave fled all Massachusetts state tax returns and pald all Massachusets state taxes that are required under law. NOTE: ‘This applles ‘even if you reside out-of-state or aut of the Unlted States ‘+ Pursuant to GL. . 112, sec. 14, ¥ hereby certify that I wil ffl my obligation to report abuse or neglect of children as requlred by G.Le. 119,sec,51A. + Thereby certify under the palns and penalties of Signature: Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1993-1995 Physician Registration Renewal Application RegistationNo. Statue Fee Repewal Date Late Foc r WMULIETIEP Correction of Malling Address: ‘Ades Qing: SEP TOPULGS? Dy FAANCLS STREET beet ANESTHESIA DoTuws ik 02115 Gyro, State Country Cade Gee Table 1) Directions: Staple check to Bottom of fore. Add late fee If necessary. + Questions 18 include information from Board files. Please cores as necessiy inthe boxes provided on the right hand side ofthe pag. + Bofore proceeding, please read the insinsction booklet. Some questions are options. ‘Make s copy ofthis form and all attachments for your own records - you will nced copies for eredenialing end other parposes. The Board will charge a fe fr esch copy it provides. «Enclose the $250.00 renewal fee by means ofa certified check, money order or personal check made i othe Commonwealth of Massachusetts i Frere nr Caran of reread Train Terman ey icyou we ee eve 2, a) Address (Home: ome oe se Te oy Gae_—— Wp © Aide es a a TE FRANCES STREET Country Code? TSS print County. VERT ANESTHESIA iaTCe, GA G2t1s Da of Binh (MID/Y): —L 1 Sex (MF). 3. Dutoof Birt: sexs Lieisve Dae: U9/10/23 SSH: Le Ieee Date (MD — amber Telephone Number: pais Home: Business, (_) C= (CTD) 752°7557 eye 4. Name of Modies! School: University of Nassachusetts Necical choot ‘Yee: Graduated: Degree (MEMOS Year Graduated: £0 Degrees MD iti — 5. a) Other sates where you ae now Viensed ta practice (Abbr): _-—T TT b) Sues whore you previously were licensed to practice (Abbr): —_-—- Cae Hows pez Week in Mass 6. Spocishy Code(s) (See Table 2): —_—— Heme ate Code _Hours per Week in Mas. ——— a Anesthesiology EOS. print speciahy: vu 7. 1) Ifyou are curently American Specialty Board Cenfied, enter Codes: (See Table 3) Code: Cote: I you previously were American Specialty Board cenfied, but are no longer, please enter codes of prior cenifiation: (See Table 3) Cote: Cote: ae 8. Drug License Numbers) ifany: 2) Federal (DEA) Federal (DEAY: >) State (MA) Sue (MAY: 9, Thave completed my CME requirements inthe two years preceding my renewal date: Yes. No, waiver requested — ‘You must fil outa separate Waiver Form. ‘The waiver must be granted by the Board before your licease will be renewed. See instractions for (CME requirements. Do not submit docurentstion of your CMEs with your renewal application. pe curceran PRINT NAME AND NUMBER: —PiysicsnLantNane TOPOLOS _ pegisvaion unter, SOPS F_ 10, Activity Status: Iam applying tobe registered with the following stame: Inactive «+ Thereby certify chat if requesting Inactive status, Iwill not pructice medTelne, Including writing prescriptions in Massachusetts, 11. My medical malpractice insurance is covered by {aX(INSURANCE CARRIE ot (0) LETTER OF CREDIT___ If applicable, check one. (tenes Comerallel [tk TMIUANCE” CO. te BE to tae Auer, nda olove Lam ein wi ACTIVE ns, bt wn ot cov medcal malas RawuosboaineT on (Check Ons () NOT INVOLVED IN DRECTIINDIRECT PATIENT CAREIN MASS. i) OTHERWISE EXEMPT: ——— (State how otherwise exempt): 12, Current Health Care Facility Affiliations. Supply the codes from Table 4 and piace a check mark next to those facilities where you have. Adoniting pre Fatty tose PL) X can) Facility Code: (AP) Facility Code: (AP) Frcitiy Code: DL Hy (apy Facility Code: (AP) uly Code: (AP) £999, print name(s) ‘Additional hopptals at which you previously held privileges and other health care facilitcs with which you were aesociated in the past 2 year, (See Tebie 4) Facility Code: Facility Code: Facilcy Code: Facility Code: Facility Code: 1£999, write name(s): 13. Are you carrently ina post-gniduste waning program in MA es resident orclnial fellow? Yeu NaXX — (Checkone) 14. «) Whats you pinsipal work soning? Seo tebe s) LQ. 1) Cereof patients in Maseachusets (MA) See instrtion booklet) A 4) How many hours per typical week ate you curreatly involved in oulpatient care in MA? 22 iusjwk in MA. 4) How many houre per (piel week are you carey involved in inpatient care in MA? 22 hesrk in MA (Questions 15 through 23 refer ta the nast ta years only, Check cther YES or NO (NOT N/A) to each question Provide deuils on Form 154 forall YES answers, Refer tothe insuiction bookle! for aduional information, 15. Has any medial muprctce clsim been made apsins ou, whether or ot «awit was filed in relation tthe cin? 16, Have you ben charged with any criminal offense, other than x minor lfc violation? 17 Have you formally been charged with o disciplined foray vslaton ofthe rule, by ls or standards of practice of ny {goverenal auhoriy health care fect, group practice or professional scl o association... 18 fa you pies opin peo rib conrad steno renee or upended eid ‘orrestricted by any sate or federal agency? 19, Have you withdrawn an application fora medical license or been denied a medical Yicense for any reason? .... 20, Have you had any mental illness which has impaired your ability to practice medicinc orto function as a sudeat of medicine? 22, Have you had an organi tness which hae impaired your ability to practice medicine or o function as a student of medicine? 22, Are you now or have you been in the past two years, dependent upon alcohol or drugs? - 23, Has any professional ibility insurance provider restricted, limite, terminated imposed a aurcharge on your COverAge? x + Purmunt to G.L. . 112, sec. 2, I will not charge to or collect from # Medicare beneficlary more than the Medicare reasonable charges. + Pursuant f0 G.L. . 62C, see.49A, I hereby certify wader the penalties of perjury that, to the best of my knowledge and belle, Thave ‘ed all Massachusetts state tax returns and pald all Massachusetts state taxes that are required under law. NOTE: This applies even if you reside outsof-state or out ofthe country. + Thereby certiy that Iwill fui my obligation to report abuse or neglect of children pursuant to Gc. 129, se. SIA. +: Thereby certify under the penalties of perjury that all Information ox ths form and Form 15 is true. 8,99 Signamre: = Dae: ‘Ten West Street, 3rd Fi 1991-1993 Physiciay Commonvealth of Massachusetts Board of Registration in Medicine ; Baston, Massachusetts 02111 - Foo Roqewal Date 7 orseasot Dr. GEORG ULOS 1 FRANCIS STREET i\ PT ANESTHESIA \ a03TIN, HA O2115= 4 irecionee 7 + Quests 1-7 cud ifermaion om Board es. Please coroc as nécaenagé a a + Botora procoosing,ploase read te lastucton book. | Anenoratronoptonevetone comp. (The etucionssecy whch quiswran onl) + Make a copy of tis form and al attachments for your own racorés-you must give health care faclae copos for redetiaing purposes, The Bcard chaos $300 plus postago for asch copy fumishod. ‘Encloso tha $150.00 renowsal foe by means ofa cartd check, monay order or personel chack made payable tothe Commonwealth of Massachusetts ‘otivity Save: ‘Tam applying 1 bo registered wit tho flowing status: active ‘hereby cory that requesting ineoive statu, ioe medicine Ih Masuechueete, Pre-Printed Information Corrections of Pre-Pented Information 1. Other Name(s), any, undor which you wore lensed: 2.) Ades (Home): 2b) Addoss (Business) 73 FANCTS CTREET OEPT ANESTHESIA PO3TONs HA U2115~ (1800, wile County: 3, Date of Binh: Sox Uc. tesue DateJ6/1E/83 sane! “Telophone Numba: Home APM 2-7357 4. Masia! SenoclcoseHAs10 Yor Grasuates © Degree: NO ‘Mame of Schon: university of Massacnusetts Medical se 5.0) Othor States where you ee now Ecansed ts race (Abr: 1) Statae where youprviously ware leaned to prectco (Ab) 6. Speciaty Code(s) (Soe Tabi 9. Sede Hows por Wook In Mags, an Q” Anesthesiology a 1.) Are you Rican Spell Board Caried? (VNHY 7) YES, Ener Coden coe: 4 Ss oare of Anesthesiology odo: '8. Drug License Number(s) (any) foptonal:a) Feder) (EAL 2) Stara (MA) #4, Dato of Br (WOM): a ue. sue Dato(ory} j___ BN Homo: Business: ae ‘School Code: 190069, wito Schoo ol. Your Gradvatoe Dogroe (MO/0O}: ‘sex qwry___} 1108, wro spaciaty cae PA rd 1) How many DEA es, do youraver 9. {have comploted my C.ME. raqultements inthe Wo years preceding my renewal date: YES X_ Waivor Requosted (You must outa separate Walver Form, Tho waiver must bo granted by the Board before your icant wil bo renawed,) See insrucins for CHE requirments. Dp not submit decumantaber of your OME'® with your renewal application. SOM - 780 -Posaers {For Otkce Use Only: Waiver Granted Date FILL IN NAME AND NUMBER: = payeaan astname: TOP LOS rogisraien no OF SF 10, My made! mpractee inturancols covered by (a) INSURANCE CARRIER_X or (b)LETTER OF CREDIT___. tappleabl, chock ene Uattosurr CRE CO Bee Atornatvely, indicate as folowe: | am registering with ACTIVE status, bull an not covered by medical mulpracien insurance becaue | am (Check ane): (NOT INVOLVED IN DIRECTANDIRECT PATIENT CARE: (OTHERWISE EXEMPT {stats how torwie ona 11, Curent Hoeptal Aiton (Supe th codes hom Table 6 an place 2 check mak oxo foseaclies whoa you have admithaproges (A). Facity Code: T=2Ii_iae) ——Facty Code:___1_(AP) Feat Gode:___/_ (AP) Fecity Code: ! 141m) FacityCodo:___ AP)“ Cade:___/_ta) 1900, wes Nar a eee te Facity Cod: Faciy Cose:_ Faaity Code: _ Fraliy Code; 1996, woke Nemes): 12, Post GraduataTrinng in Massachusetts (MA) (See insbucton booklet) «) Ace you currenty in@ post-graduate training program in MA as a resident or cna flow? Yoe___. No.2 (Check one.) ») Ifyou are in a MA program, are you a |) Raékient__ 1) Clinical Fetow___ or f) Research Folow__? (Check one) 2) How many hours por ypica woek do you spend in thie MA post graduats wining program?_Pre wk. In MA. 12 Core of Patt a Massachusots (MA) (See et uoton bocklot) ‘) How many hours per typical week ere you curently Invlved in ouaetentcarein MA? ELS ta MA. ') How many hour par pial week are you cueniy invlvedin ination caren MA? vin MA. 14 Principal Werk Seng 18) What your pricial work sting? (Soa Table ‘Questions 16 through 22 refer to the pas! four veers only. Check elther YES or NO (not N/A) to sch question. Provide detalle on Form 18A. Yee He 15, Has any pancing or new medical malpceciceclsim boon made againat you (whether cr nota lawsuit wes fled in ceation to the dim)? 18, Have you boon a dofendant in any ponding or now emi! proceeding ner tana miner Wate O6N80 7. nnnssannnennn 17, Are any format signa charges ponding or has ery dtcpinary action (as defined by Bcerd requlaons--Soe lnsvucins) been ikon sgshaiyouby any governantl eutoiy, opin rt hath cr fay sienna mae etcoutn fired, cleo, sate orca... fs 18, Has your priviege @ possess, dspents or prescribe conte subtnoes been suspends, revokod, doned,resticte, surrendered, or have you boon calla befor or bean warned by te tae or ay othr jraciction inching a federal aponcy?. 19, Have you witérawn an apelin fore medical anso ox boon driea mocicaloanse for any reason? 20, Have you had ny montanes which has Inpiod your aby opracion mascine oo furcon as a student of most 2. Have you hed an oxgaicinets which has pid your ably to pracice medina oro notion a e sudan of medicine’, 22. re you now, ox have you buon inthe past four year, dependent upon aloo or drugs’, Purauent to M.G.L. 0476, wil not charge to or collect from « Meclioare beneliclary more than the Medioare rexconable charge for my services, Pursuant to M.@.L. 0.620 200.484, | oertty under the penalties of perjury tht, to my best knowledge and ballet, have fled any Massachusets sate ‘wx rature and pald any Maeeachvestie stat taxes, thal are required under law. NOTE: This applies even If you teakle out-ofetate or out of the ‘country, ‘cont that | wil fll my obligation to report abuse or noglct of children purauant to N.GLL.0:119 s40.51A, | hereby certify under the penaltles of perry that ul information on tha form and Form 15A le true. a awry PT farsod mn FH BOARD OF REGISTRATION IN MEDICINE SEE REVERSE o1DE TEN WEST STREET Sk TED vo covevere te ques. uae ‘Tiahdge SAND on ROSE SEPT soston|Massacruserrsoar: = SE |. HH 1) TMS NASER Ae Sons fon oer kics) Cota aee anno PNA ANGWENED ves: ro aussrions 15 : Tunouoh YoU Muay chet misao en — PLEASEUSE THE ENCLOSED RETURN ENVELOPE LICENSE a ree [ANTONCRENEVED | LATE FEE THIS APPLICATION MUST BE SIGNED Tes aT AMOUNT noe SE] NOTE! {No AURA Wien Sctae 1 50937 $100 | 100 | 07 24) 87) QhoEi te PRereNntD GenaONAL, MD 5 RPE te neces a - S naa. re ‘CoMMONWEALTH OF MASSACHUSETTS. GEORGE P TOPULOS 75 FRANCIS STREET DEPT ANESTHESIA TEN WEGT STREET, 2nd FLOOR I ‘BOSTON, MABEACHUGETTE tettt LEAGE PRIN Aer NAME OR ADDERS BOSTON, MA 02115 SS eo "oomunr nen me meynucronswoieno wis Sono Maven QUESTO 144 1. Pinthres GLOPGS T2LULOS 2 Duet Bnt — eg aap 2. Maal sent Gece tae wo? B} 002 L] eraoms 4 county wherein sero iocamt: £8. owectaratntin: MAY J7B2 * Aan oy ne cntet ee wnenoonen ANCHCS 102g 1. ese Seca Micecthesseloat 1 Preoplon eing ee 8. Home agares: 10 Princ puenese ease: 1. tal hounaa eh ou hw curate pepe onten's Hospivead ; Me splitted 1, Lita how at when you have net organ in tne pen20 years: A AZM. Mosby 48, sts cher an Masachusersnwhich you sre prosontyKemaadtopncon: ALONE 14. Litany cna states where you wer provcusy Heanssaropnecten MUN NCSORQ ves N 138 us any mai! matprecte clin ben ad gens youn the sn yrs (ether oF Noa awit wed in eton othe esi? 18 Have you, ey ne. boon a delendant in any exninalprocadng otter an minor tae oes? a Ripa Ten kt huge alg ota ery Sey co bee akon aya TTR NAVY SST tuinor ale ban cae acy bral mada! excelent aterdaai orice | 4 cn your oiviogs to potbesn. apenas rivaled sbsares oe! boo Supandes,oked Ta shave you been cale blots or naied sy sas” my Oe uradedcn euch fae sgney. tay ne? J 38, Hove you evr witharann an appeal or mecca! leanaure or been dered x medical canes for any tear? 32, ve you ovr ned any ant nes which has inptired you aby Wo ration madeine oo tune a want redo? ee 2 ve you ovr bad an organic ners mich es imped your ai lo paces min ot uncon a ude of meciie? 42. Arayou now, or hae you boo nthe past dapenden! upon leona ra? _ 41 Have you eer. foray auton, ost Arian Spacey Bosra Gatlcnen? ty ‘Uae you Beer dared racriaton by one 6 ror spol Bona ijn with ont) 25. {hme competed my CME. roquiremens in the to years ering one renawa! dale a lows: eo. ALG 28 tamanccive Cece [El peter: tO |MEREBY CERTIFY UNDER THE PENALTY OF PER.URY THAT ALL INFORMATION ON THES FORM (FRONT AND BACK) INCLUDING ATTACHED SHEETS 1 TRUE BUROUANT TO CHAPTER 475 OF THE ACTS OF 1995, WILL NOT CHARGE TO OR COLLECT FROM A MEDICARE BENEFICIARY MORE THAN THE MEDICARE REASON [RBLE CHARGE FOR MY SeAViCES. TURBAN TS MOL: 4,08 CORT CERT PENALTIES OF PERUURY Tur LTO MY SERTAMOWLEDOE AND DELEE KAVE RAED AL STATE TAC FETGANS AB PAU a Sta fe PAL nesUeS ONSEN ON RLEASE NOH. MOL CUE VON QUES BUSES TE GA LSE (Bee Revere sid) ee: ‘Commonwesith of Massachusetts Board of Registration in Medicine 009931 ae: Sor Wes Seer ior. Boston Magee O13 4 too. 1081 Physician Regina Renewel Appcavon, Page ¥of2 Fegieaontie. Bui For Ronnie Be z GEORGE F ToPuLos 73 FRANCIS. STREET DEPT ANESTHESIA BOSTON, WR 02115 Teponare eat acararig nercton ara tre comping (Gon eu eat pia acon feet gl orp ot neers “ct al tr opta quis Uta eh fo) ey la nota sit athe Dourdan hat norton ‘Sorte onal pace se tli eage one ad fhe hunted pages rm para ove Sent it yen rtd a shar ar oon a nha cane ea ees vanes TOPULOS wee Feorge ty "Bota Numi any. you wae wera de eee 2.) ses ing: eu shes ia saat 28 pena —ROSTAA) Ma adi abe 2m tas ama) 2g ksduee Guineas 2S 2. Ylponn anna (617) P Sd ~ 2 3S Protein ‘2 Tewphore Home) Optom: |) : Dain of Boh MO/DAM_ ‘Sc WALE X FEMALE 5. Goal Set No, eon . 6.) cic Seo oc a Tab MAD Lb 9800, wr Maes euvew cucu 1990 ea deaee WO 00 oe eee eae a _ eee as rat Siig etn, ee oe eos her esky Palani ser ey | SSE os el hy ion cat rn #=— S55 eas Zot = agguyen ei sateen oe eyo fc seetitatadeadtistrrsitteat ‘anes htts pcyavaGr W Y_woES e we Bw) | pia ae ae eee eS I. EE, fee, & Sear ea eeeeteomenne Pe etenetie ee ecee meeett nd Ot eteee Syl eta bereeMica 1001 ot mac eerat tenes a eenerec q Srideaee . SS, ee mesenonttemes se cde esse Etta ou epsom 2c al eae cic "icy epn a wic youve susan oct oh ath Ca Faw ic you we anor Pent Pate Tine ech Sermo | Foreain 92) 122 6 fctyooms_ | Fone 224 “2S Remy eo =~ 8 | 100, hen 1.8) Alina eine won ou eel bplnge an ti Hab Cae Fie Pw you war accede pt 0) | (Se Tne 4), | Faswy case 22 7 "har crty tt eagaing INACTIVE enw ot prea asain be Manachat uu MG 078 wl sarge or oat om 4 Malte Sastry mora than the Madera anna charge ft my sane A ng Raine ta ane ea teaeeL Lee tt Heel ts to an you rnce sues xk he ou ray erty unde pats of prary at rman on 1 forma Dacha e}__atuched aageeie us, wun Hewige P lof. Dae 7 9F a Maweachusette Bourd of Reglstration in Mace 1086-1001 Renewal Applicetion, Page? of? ruivsaneaninander, Poylian et tane: TOLULOS guaran te-n1omeSumeshr youu noe tenes npccn aban WOME 12.0 Sats hore you previo wor larene to fraction sores: MOE taiemepngocengancwnnetcigeen: — GAT) “NACTME Ag ae oun ) “since my CME aoc in anny aeemilanuao Pn dump tea ot) 2 tn Sk fibirees A he hecney ogni SA peste tre nore wero) “ neta ego nace ecm by GORGE OAETIE) \ETEROF EON "reece, ack 00 ed yt oa rawr RECO. ret Ca ‘oan ti aicirg wit RINE al oats by raion aa ates PRETO NOTRNOLED NCOECT/RORECY PATIENTCAFE— OTMERAISEEXEWOTED "i ow) 14) Peete Paton Toran Manat: 2% Cease 1g) 1 rien oy. Charters NO WA GD Hen, Pro cl a A aces 1s nas ay peag om ro raps can been mace au yu aetna at wa a ono a 1 hse you baa tana any geedg eC en oseaing ar han ie tae tes "erm ee err geen ad you mawered "VES te qvton 118,01 rove deal on Form 16h atacha, Caton Y8 tg 24 whom zl trata cy, Coch sta YEO NO (ok N/A ach oweuten. Praia hh racescton, Yan No naan ata arte eer Re ay she krndetes eang 8 eager +2 save ouwindaws an appa framers buon dara dene ny Wah? £2. jnve youn ny reine win haart you ayaa ube a ase ot rad 2 bn outa napa tree apd yur hyo pace mas oro onoen a canto ade. 12 Kyou now, char you duane as, dopant upon esl og? Ha you nye, et Anata Sot Bod Cito ia ‘bn you ben eid raersctan by rw rave tpcay bev YES et ont Commonwealth of Massachusetts Board of Registration in Medicine 860 Harrison Avenue, Suite 4G-4, Boston, MA 02118 (617) 654-9810 http://www.massmedboard.org Physician Registration Renewal Application Before proceeding, please read the instruction booklet. Copy this form and all attachments for vour own records; you will need copies for eredentialing and other purposes. This completed renewal form with attachments must be returned in the _excen envelope gi least ¢ weeks before your renewal date, ‘Remit $400.00 for renewal fee (non-refundable). Return renewal application in GREEN enveloy : i ‘ 4 Please review carefully the following information for accuracy and completeness, Make diy eitections or eae alterations as required. All questions must be answered or your renewal will be delayed. 2 £3 = om Renewal Date: ona 20 1. Curent Suna: Active Registration No.50937 you wanto change your current satus, please check ate ofthe following boxes to indicate vores : Dactive Retiring (see instructions) Di inactive (see instructions) Oo vol dow < 2. OierName() if ey, unde which you were ensd Howemtecoreionnny "FD 'A) Mailing/Business Address: other Name(s) Ty Name Chagge Ger Wn below) 3. GEORGE P TOPULOS 75 FRANCIS STREET Malling Address DEPARTMENT OF ANESTHESIA | City/Town: ‘State: BOSTON, MA 02115-6110 ees ea eeeeee at B) Fome Addtass: ances Agnes caeemeerorere rere rence CiyrTown Tae! zip eat [Business Telephone: (___| Nome Phone: Busines Phone: PLEASE NOTE: Oniy one adives can boa rralling address cannot bea P.0. Box, 4 Dat ofBins DiSex M7. Curent Ameicen Boar of Medial Specaies Ctieaton (Ss Ile) ‘Coie: A Code (©) SSH: Drag License Names, fn: 5, a) Name of Misa choot: oicaeal DEAy ‘University of Massachusets Medical School ye atassrcesete b) Year Gradaated: ©) Degre: 960 MD, 9, a) Other states where you are now licensed to practice (Abbr) 6, Specialty Code(s) (See Table 1) — a Code(s) 'b) States where you were previously licensed (Abbr.) ‘AN 0. Anesthesiology orien 7 Hesse cee aeeeeetegeee 10, List all current health care facilites at which you aze afiiated or have completed the credentialing process forthe provision of patient care. (Supply the codes from Table 3 and place a check mark next to those health care facilities wheze you have admiting privileges (AP). [Next to each facility, write the approximate percentage of patient care hours that you provide in each facility). __ No affilitions. |__(AP)__% Facility Code:_ ( (AP) __% Facility Code |__(AP)__% (any Frcity Cote LW tae) IF” % racy Cote: Facility Code: 9 247 (AP) S" % Facility Code: Tae pane ae PRINT YOUR LAST NAME: TOPVLOS _ LICENSE NUMBER: SO? ze : 1, My medical malpractice insurance is covered by Xf Insurance Carrier [J Letter of Credit Insurer's name, Required) C/E CO Policy dates: From _) / 1 /Q2 T/A/Z/1OF Alternatively, indicate as follows: I am registering with Active statas but I am not covered by medical malpractice insurance ‘because Lam: Check One: [] Not involved in direct/indirect patient cere in Massachusetts (] A government employee. C1 Otterwise exempt Please explain exemption: 12. What is your principal work s (Sec Tabled) _/ 2 you are affiliated with a healthcare facility or credentialed for the provision of patient care you must complete question #10 on page t and list your affiliations. 13 Care of patients in Massachusets (see instruction booklet). 1) Average weekly hours involved in: A) inpatient care hsv B) outpatient care _bra/wk 2), What is the approximate percentage of your patient care hours in primary case? 2% = 0) ow) rT. ARS, UCT 7 Has any medical malpractice claim been made against you that has not yet been finally seitted or adjudicated, whether or not a lawsuit was filed in relation to the claim? 15. CLAIMS (Besolved):. Has any medical malpractice cleim that has been made against you been settled, adjudicated, or otherwise resolved, ‘or not a lawauit was Bled in relation tothe claim? | 16, Has any lawsuit, other than a medigal malpractice sit, which is eted to your competency to practice medicine, or your professional conduct in the practice of medicine, been filed against you or been settled, adjxticated or ‘otherwise resolved? 17, Have you been charged with any criminal offense? 1} 18, Have you been charged with or disciplined for any violation of lawa, rules, by-laws or standards of practice of any governmental authority, beelth ate facility, group practice or professional society or association? 19, Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied, reatristed by, or surrendered to any state or federal agency? 20. Have you withdrawn an application for a medical license or been denied a medical License for any reason? i 21, His any professional lability provider restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency or conduct on your coverage, ot have you voluntarily restricted, limited ot terminated your insurance coverage in response to an inquiry by & professional liability insurance provi 22. CME CERTIFICATION; Have you completed your CME requirements preceding your renewal dae? Ves] No 1 CME Waiver. CME waiver form must be submitted a least 30 days price to license expiration date, CMEEXEMPTION: Checkone:| [7] Inactive status [) Residency/Fellowship training (See instructions). See Instructions for CME walver pr exemptions. Do not submit documentation of your CMEs with applteaton. + Pursuant 10 O.L. c. 112, See 1A, Tunderstand my obligations to report abuse or neglect of children under GL. ¢, 119, Sec, S1A. and the punishment fo fashure tp comply. + Pursuant 10 G.L. . 112, Sec. 2, J will not charge to or collect from a Medicare beneficiary more than the Medicare fee schedule amount. ‘+ Pursuant to GL. c. 62C, 49A, I bertity that I have complied with al laws ofthe Commonviealth related tothe filing of “Massachusetts state tax returns dnd payment of all Massachusets state t2xes; reporting of employees and contractors under ‘nd withholding and remiting child support pursuant to GL. 119A. (See instruction}. 1 hereby certify under the penalties of perjury that al information on ths Renewal Application, Part B and Form R fs true. rd Regule isire that vo B nwa ange of a MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. | eee eee THE COMMONWEALTH OF MASSACHUSETTS *s9¢oved: a oN Seer a i BOARD OF REGISTRATION IN MEDICINE date: _ | appli otdtonement Regcmtion ~ NATIONAL BOARDS te (Fee — $500 must accompany APPLICATION — No currency of personal checks) 4 @, So) 83 159,©°_ For Office Use eenay SDAIG ® By: aa 7 Pa eee eee Fort of Fee! 5.12.0. ue Certiinte # —SHOOBZ due or raul 16 Pleaye Print j : SWORN STATEMENT 5,0, a Mailis

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