» Commonwealth of Massachusetts Board of Registration in Medicine 1 ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086 : utpufwww.massmedboard.org Physician Registration Renewal A Before proceeding, need copies for credentialing and other pui ‘gceen envelope 4 weeks before your renews + Remit $250.00 for renewal fe. + Aad late fe of $25.00, iF necessary Please review carefully the followin alterations as required |, Current Situs: Active Registration No.299257 Renewel Date: 07/23/2001 Ifyou want to change your current status, please check one of the following boxes to indicate your new status: (Check only one) Base ClRetising (see instructions) Dinactive (see instroctions) Do not wish 10 renew 2. Other Name(s), iPany, ander which you were licensed eee eee (Other Namets: = 3. A) Malling/Business Address: Mailing Adare s ing Avan Daniela A Carusi City Town: State County: [Business Address: 75 Frances Sp | 1B) Home Address: cay/lown: Bastpa Sa a ip: DABS Country: BAT Business Telephone: (let?) 732 -tele@O Frome Acres City/Town Count Home Phone: Hom Telephone ( - Business Phone: PLEASE NOTE: No P.O. Box addresses for home or business addresses. : 7, Current American Board of Medical Specialties Cenufieaton (See Tale 2) 4. al Date of Bat: biSex: 5 Code: Code: 5. a) Name of Medical Schoo! oy YUU Paonia Shon fae, SF 6. Specially Code(s) (See Table 1) Code(s) Hours oer Week in Mass ORG 0 9 Obstetrics and Gynecology Drug License Numbers. if anv: a) Federal (DEA): >) Massachasens: 4) Other states where you are now licensed to practice (Abbr) b) States where you were previously licensed (Abbr) 10. Current health care faclties at which you have completed the credentialing process forthe provision of patient care, (Supply the codes from Table 3 and place a cieck mark next to those healthcare facilities where you have admitting privileges (AP) [Next to each facility, write the approximate percentage of patient care hours that you provide in euch ful Facility Code: od 1) (AP) La0_ % Facility Code:___/ Facility Code: 1999, print name(s) (AP) ___% Facility Code: L (ar) ta) % Facility Code: % Facility Code: (AP) (ary ees 1PRINT YOUR LAST NAME: ('G4uSi is LICENSE NUMBER: 220902 7. 11, My medical malpractice insurance is covered by a) [3B Insurance Carrier b) [J Letter of Credit aos Name of isurer_ LAC ‘Altematively,inicste as follows: Jam registering with Active status but I am aot covered by medical malpractice insurance because | am (check one) 8) Not involved in diectindirect patient care in Massachusens >) [] Otherwise exerpt lease explain exemption: Laie 12, Ave you currently in a post-graduate training program in Massachiserts as a resident or clinical fellow? (check one) [) Yes 63 No 13. A. What is your principal work setting? (See Table«) J On B. Care of patients in Massachusetts (see instruction booklet)” 1) Average weekly hours involved in: 8) outpatient care LT _hrshwk b) inpaticnt care o€ S hrsiwk 2) What is the approximate percentage of your patient care hours in primary care? £7 _% 14. CLAIMS MADE: Has any medical malpractice claim been made against you thet 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 medical malpractice claim that has been made against you been setled, adjudicated, or otherwise resolved, whether or nota lawsuit was filed in relation to the claim? Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, ‘or 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 3 minor traffic violation? 18, Have you been charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of any governmental authority, healthcare taciliey, group practice or professional society or association? | 19, Has your privilege to possess, dispense or prescribe controlled substances been suspended, evoked, denied, restricted by, or surendered to any stete or federal agency? 20. Have you withdrawn an application for a medical license or been denied a medical license for sny reasoe? 21, Has any professional liability insurance provider restricted, liited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency oF 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 renewal date? BQ Yes [] No - D1) CMEWaiverrequested-(CME-waiver form duc 30 days prior to dateof license expiration)" - —-E}CME-exemption~ ‘See Instructions for CME requirements. Do not submit docomentation of your CMEs with your renews! spplication, Pursuant to G.L, e112, §2, willnot charge to or collect from a Medicare beneficiary more than the Medicare (ce schedule amount. Pursuzat to G.L.€ €2C, § 494, tothe bes of my knowledge and belie, bave Mile all Massnebusets sat ax returns ad pada Massachusetts state tars that are required under lav. NOTE: This applisevea i you reside out-of-state or out ofthe United States, + Pursuant 10 GL c. 62C, § 474, to he best of my knowledge ond bellef, Iams in compliance with M.G.H.C. 119A relating to withholding and remiting Child Support. + Pursuant to Ge &112,§ 14, Hill fof my obligation to report ebute or neglect of children as required by GL. . 119, § SIA. + Thereby certify ynder the penalties of perjury that althe information on the Renewal Application and Form R is true Signature: pate: 6 /o2/) G/ YOU MUST SIGN AND INC DE PART B, WITH YOUR RENEWAL APPLIC CATION i that you not in writing, of amv change of add MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. 2Application: 209 0571 + Date of issue: Commonwealth of Massachusetts - Board of Registrati is ar 10 West Street, 3rd Floor EG & WE. Boston, MA 02111 - (617) 727-3086} D} { TS'-6 200 | U EI PLIC, IN a Application Fee: Please enclose a check or money order in the amount of $35 Bayable to the Commonwealth of Massachusetts, Gheck One: [@_ U.S/Canadian Graduate 1 International Graduate Legal Name (do not use nicknames or initials, unless they are part of your legal name) CAEUS\ NVELA Last Name (type or print clearly) ‘First Middle ‘Suffix (Jr, ete,) RMD. O00 PhD Other degree. Other Name(s} Used - List any other name(s) you have used which may appear on your identifying documents, such as medical education and examination records. If not applicable, check here: gS Entire Last Name (type of print clearty) First ‘Middle Suffix (Jr, etc.) Date of Birth: Social Security Number: _ Month Day Vear Place of Birth___Mounrfin View. Cari eorwit iy BietrProvince Teron, Coariry nar OSA Home Address: Ba suonbeT aad Bret City fa ‘State/Province/Territory Zip (or postal) Code Business Address: Bes tusana_ st 3 sr. Number and Sree Bosmy MA ozs City TiietbrouncaTTentony Zip (or posta ace Business Home Telephone: (4t?_) 712 “leva _, ext. $1222 _ Telephone: Be Preferred Mailing Address: §§ Business Address O Home Address EF [1d I GlooPage -2 APPLICANT'S NAME: DAwieta CAeysi : Pre-medi ichoot . From Facility Was Calfunis lo Angles Degree: 8.5 ar fem MAGA Street: if, City: Loe Anyeles State: G4 Facility. Degree: ee dee eee eee ‘Street: City: State: Medical Schoot as beni Degree: M.D. Tree Baa il 4 is Gi Ran Fran seo State: CA Degree: dd. wd. City: ‘State: Date of medical school graduation: _5/23/47 Note: U.S. graduates must include a written explanation for the duration of medical education tonger than four (4) years, and for any breaks in medical education. Intemational graduates must provide a written ‘explanation for the duration of medical education tonger than six (6) years and any breaks in medical education. poatge sk Hecheat a See Uist ail postgraduate training chronologically from medical schoo! to the present, the name and address of the facility, your position, e.g. PGY 1, 2, fellow, etc. and dates of affiliation, You must account for all periods of training or postgraduate work from the time you graduated from medical school. Faclity: Beouam & Waoen's Hose uaz. Position Pot 1-4 Ehren prealet Street: =I Feavess st ==" city: Bisa) State: aia Facilty::. : Position: ieee) Eee fd CSEE Street City State Facility Position: Wd tt Street: City, State: Facitty Position: (ney a Street: city: z State: Facility Position: ye yaa. Street: City: Slate:‘November 27, 2000 This addendum addresses my medical education lasting longer than four years, as requested on Page 2 of the application. attended the University of California, San Francisco, for a total of five years in pursuit ofmy M.D. After completion of the standard curriculum for the first 3 years, I elected to complete an additional year of research. During this year I remained enrolled as a full- time student at UCSF. f initiated and completed a clinical research project, which culminated in a formal thesis and a publication. I also continued to see patients 1-2 days per week in an ambulatory practice as well as in a volunteer community health clinic. When the project was completed, I resumed my final standard year of medical school. ‘Though I extended my education from four years to five, there were no breaks in my medical education. Daniela Carusi, MDAPPLICANT'S NAME: NiGLA 5. 7 Hospital Affiliations and Employment List hospital appointments where you had active staff privileges, including the name and address of the facility, your position and dates of affiliation in postgraduate training, in chronological order. Also include periods of unemplayment or employment outside of medicine. Attach a separate sheet of paper if necessary. From To Facility: Bed utr x Womens Heserae Position Pay 1-4 Ole/25 197 ob/ 22 100. Street: 25" FeanesS 5 City: Boson State: jaa Facility MasAtuusens lreneere Hustrrac Position Puy |- 94/25/47 ol./2z Joo Street: Ba avis Sy City, Boson State: aa Facility: Position: fistan 3 oe Street: City. State: Facility: Position: ee eae Street: City: State: 1. List other states (abbreviations) where you are currently or have ever been licensed: ___ 2, Are you certified by the American Board of Medical Specialties? [] Yes f No 3. List Board Certification(s): 4, Have you attached an up-to-date copy of your curriculum vitae? Yes (No 5. Reason for requesting a Massachusetts medical license: EZ Pla ta_Gonhinae Deeubiccay Meditiae 65 am ORM ya io MA sins cach se 1S. 6. Name of Facility: ca is 7. Address:_75- Fetes re City Rasp 8. Anticipated starting date in Massachusetts: 07 /.O1 (Qo Affidavit of Applicant |, the undersigned applicant, hereby certify that all information included in this application for licensure constitutes a true statement made under the penalties of perjury. é a act UW Luloe ‘Signature oF Applicant Date‘STATE LICENSE VERIFICATION Commonwealth of Massachusetts Board of Registration in Medicine- 10 West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086 STATE LICENSE VERIFICATION i : Complete the waiver for release of information and forward this form to every state board where you are currently licensed or were licensed in the past. ‘s Weiver for Release of information: |1am applying for licensure in the Commonwealth of Massachusetts and the Board of Registation in Medicine requires that this form be completed by each state where | hold or have ever held licensure. | hereby authorize the release of any information in your fles, favorable or othenwi i ‘Signature of physician: de é Date (jut 1 oo Printor ype name Danitle Ca cus License number:4'7- $40) -O | Status oflicense: JaActive [Inactive [) Other. Mussachusse s TO BE COMPLETED BY STATE BOARD 1. Name of medical schoo! of graduation. _Date of issue: ff 2. Date of graduation: License number 3. Basis for licensure: Tame) ol medical ieenting examinatonste) 4, Expiration date of icense: ___/_ 5. Status of license: (check one) ( goodstanding [] revoked [] suspended 6, If revoked or suspended, please explain: YES NO 7. Has the licensee ever been on probation? ooo 8. Has the licensee ever been requested to appear before the board? o oa Wyes,” please explain: Other derogatory information: Remarks: Signed BOARD SEAL Print Name: Title: State Board: PLEASE RETURN DIRECTLY TO THE MASSACHUSETTS BOARD OF REGISTRATIONMALPRACTICE STORY Commonwealth of Massachusetts - Board of Registration in Medicine. 10 West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086 MALPRACTICE HISTORY Applicant's Instructions: Compiete this waiver for release of information and forward @ copy to each of your current and past liability carrier(s) over the past ten (10) years. You must account for any gaps in your claims history. If you have additional liability carriers, you may photocopy this form. Please return the form(s) with your original signature to the Board of Registration in Medicine. iver for | authorize my professional liability carrier(s) listed below to release to the Commonwealth of Massachusetts, Board of Registration in Medicine, my malpractice history and any and ali claims or actions for damages, including the following: 1. the name(s) of the claimant(s) 2. nature and date of claim(s) 3. amounts paid, if any, and 4. ‘other disposition or information in its possession, custody or control ‘on my current policy number, and/or any other policy | have had with this or any other carrier. H IE APPI T NI EN ID, A COP’ TH MPI INS, DISPOSITION OR JUDG! OF FT MUS” Dik TLY TO THE BOARD. ay met Famctect' aa ! Rok Man fame il i Sk. Go, Utd. From: (¢_/ 92 To: 2/01. City: wt vi As State: _wt A Policy Number: CRC.100 24 Rik Liability Carrier: From: jae Oetity City: State: Policy Number: Print Name:Name: Daniela Carusi ‘Supplemental information for question #12: Medical School Training 1 added one year to my medical schoo! training, thus completing my medical schoo! education in five years. During this additional year, I remained enrolled in my medical school (the University of California, San Francisco) and conducted a clinical research project in the department of Obstetrics and Gynecology. The entire year was devoted to designing and implementing the study, which culminated in a thesis overseen by the school’s MD with Thesis Committee,a x reson 33) Commonwealth of Massachi Ten West Street, Third Floor, Boston, Massachusetts 02111 [ RENEWAL APPLICATION - LIMITED LICENSE IMPORTANT: Please read the accompanying instructions before completing this form, and print legibly or type your answers, .GE 2. ‘LI Section A: 1, Name; (Lasts, inn DAVILA om_“” Telephone 2. Mailing Address: ‘Number: e City, State and Zip: _ 3. Name of Training Hospital: ae en omens ano 4. Current Limited License Number: 2-SSo2-- a 5. Other states (abbreviations) where you are now fully licensed to practice medicine: Section B: To be completed by program director. Has the physician been subject to past or pending disciplinary action in this program? CD Yes X] No Thereby certify that the above-named physician is in good standing in the training program. Print Name: “ 2 Dd. Date /Y 1 AQ Signature of Program Director: eet Telephones (o ) 23) -Gua Lf To be completed and signed by the designated official of the institution at which the applicant has received an appointment. This centifies that_DANIE IA CARUS hhas been appointed to the ‘ieee ae position of: ([] Intern §Q Resident [[] Fellow asa PGY. Facility: es Program Name: Beginning Date:_CO_/ 20/.9°F Anticipated Completion Date of Training: (_/.30 ) O/ Is the program accredited by the ACGME: Yes [J No If no, is there an approved AOGMA paneram Mapplipent's specialty? Yes [[] No ica) Education Designated Offciel,_ Graduate Med} Telephone: 617-782-8540 ‘Prams 4 iy Veamr® Designated Official’s Signature: Date: U/\G 9.name Nauitle Caucus! seer SECTION C: Read the instructions. Check either YES or NO to each question. Do not answer N/A. Ifyou answer YES to any of these questions, you must provide details on Limited Supplement attached. XES NO ‘SINCE YOUR LAST RENEWAL 16. Have you been terminated, granted a leave of absence, withdrawn or had to repeat a year in «8 postgraduate-training program? 17. Have you been denied the privilege of taking or finishing an examination or have you been accused of cheating and/or improper conduct during an examination? 18 Have you, for any reason, been denied a medical license, whether full, limited or cr temporary or have you withdrawn an application for medical licensure? 19, Have you voluntarily surrendered a license to practice medicine or any healing art? 20. Are any formal disciplinary charges pending against you, or do you have knowledge of any pending investigation into your professional competence or conduct by any governmental authority, health care facility, group practice or professional medical society or association (intemational, national, state or local)? (See definition). 21. Has any disciplinary action been taken against you for violation of laws, rules, by-laws or standards of practice by any govemmental authority, health care facility, group practice, or professional medical society or association (international, national, state or local)? (See definition). 22, Have you been denied medical staff membership, or advancement in medical staff status, ‘or has such denial been recommended by a standing medical staff committee or governing body’? 23. Have you, for any reason, withdrawn an application for hospital privileges or appointment? 24. Have you voluntarily relinquished medical staff membership? 25. Has your medical staff membership, medical privileges or medical staf status at any hospital been limited, suspended, revoked, not renewed or subject to probationary conditions or bas processing toward any of those ends been instituted or recommended by a medical staff committee or governing board? 26. Have you been charged with any criminal offense, other than s minor traffic offense? 27. Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted or surrendered, or have you been called before or wamed by any ‘state or other jurisdiction including @ federal agency regarding such privileges? 28. Has any medical malpractice claim been made against you, whether or not a lawsuit was filed in relation to the claim? 29, Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your professional conduct in the practice of medicine, been filed against ‘you or has such a suit been settled, adjudicated or otherwise resolved?: ee KoNhl nea Espace 5802 i ee ee Commonwealth of Massachusetts - Board of Registration in Medicine Ten West Street, Third Floor, Boston, Massachusetts 02; RENEWAL APPLICATION - LIMITED LICEN: IMPORTANT: Please read the accompanying instructions before completing this form, and’p 1. Name: (Last) C-n@urni (First)_Neoul Gu 2. Mailing Address:_ - Number: State: cit a 3. Name of Training Hospital: _iStinitnim o wWowenss Re 4. Current Limited License Number: 917-502 —Oy 5. Other states (abbreviations) where you arc now licensed to practice medicine_ Indicate whether full license (F) or residency or training license (L). Oe Oe O® Oa De Dw SECTION B: To be completed Has the physician been subject to past or pending disciplinary action in this program? O yes oe No To be completed and signed by the designated official of the institution at which the applicant has received an appointment. This certifies that__Dyaniera Caoausi hhas been appointed ‘anc Ante to the position of: (C] Inter [X} Resident [] Fellow as a PGY. Hospital Name: BRIGHAM & WOMEN'S HOSPITAL speciaty: Of 1G Beginning Date:__G@/QO_/G-7 Anticipated Completion Date of Training:__(a/30 /O) Is the program accredited by the ACGME: Yes [] No Hg, s there an approved ACGIME regain pica’ spesiey? Ove O es ai Designated Official: Graduatefyedical Edycdtion “Telephone: 017-782-8540 Tatas Tay Designated Official’s Signature: AA Date: 3/10/00NAME_DAwneva CAveuass u SECTION C: Read the instructions. Check either YES or NO to each question. Do not answer N/A. Ifyou answer YES to any of these questions, you must provide details on Limited Supplement attached. SINCE YOUR LAST RENEWAL Note: These questions apply only since your last renewal. 16, Have you been terminated, granted a leave of absence, withdrawn or had to repeat @ year in 4 postgraduate-training progrem? 17, Have you been denied the privilege of taking or finishing an examination or have you been accused of cheating and/or improper conduct during an examination? 18. Have you, for any reason, been denied a medical license, whether fall, limited or ‘or temporary or have you withdrawn an application for medical licensure? 19. Have you voluntarily surrendered a license to practice medicine or any healing art? 20. Are any formal disciplinary charges pending against you, or do you have knowledge of any ending investigation into your professional competence or conduct by any governmental authority, healthcare facility, group practice or professional medical society or association (international, national, state or local)? (See definition). 21. Has any disciplinary action been taken against you for violation of laws, rules, by-laws or standards of practice by any govemmental authority, health care facility, group practice, or professional medical society or association (international, national, state or local)? (See definition). 22. Have you been denied medical staff membership, or advancement in medical staff status, ‘or has such denial been recommended by a standing medical staff committee or governing body? 23, Have you, for any reason, withdrawn an application for hospital privileges or appointment? 24, Have you voluntarily relinquished medical staff membership? 25. Has your medical staff membership, medical privileges or medical staff status at any hospital been limited, suspended, revoked, not renewed or subject to probationary conditions or has processing toward any of those ends been instituted or recommended by a medical stafT ‘committee or governing board? 26. Have you been charged with any criminal offense, other than a minor traffic offense? 27. Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted or surrendered, or have you been called before or warmed by any sate or other jurisdiction including a federal agency regarding such privileges? 28. Has any medical malpractice claim been made against you, whether or not a lawsuit was filed in relation to the claim? 29, Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your professional conduct in the practice of medicine, been filed against ‘you or has such a suit been settled, adjudicated or otherwise resolved?gD Commonwealth of Massachusetts d of Registration in Medicine poster Ten West Street ston, Massachusetts 02111 (617) 727-3086 VERIFICATION OF PREMEDICAL AND MEDICAL INSTRUCTION AND GRADUATION INSTRUCTIONS TO THE DEAN OR DESIGNATED OFFICIAL OF MEDICAL SCHOOL Please complete this form in full and return it_DIRECTLY TO THE ADDRESS ABOVE. This Verification cannot be accepted nor can a license be issued to the applicant unless you send this form directly to the Board of Registration in Medicine. Thank you for your cooperation. I CERTIFY THAT __ Daniela Anne Carusi. CREDITABLY OF APPLICANT COMPLETED AT LEAST TWO YEARS OF A PREMEDICAL COURSE INCLUDING PHYSICS, BIOLOGY, INORGANIC AND ORGANIC CHEMISTRY AT: University of California, Los Angeles Bi LOCATION OF x CATT iSTITOTION NAME AND LOCATION OF SECOND UNDERGRADUATE INSTITUTION (IF APPLICABLE) for admission to:_uni f California, San Prat Sie Or Sane Stace San Francisco, California WOCATTON.OF MEDI SCHOOL (CITY, STATE, COUNTRY) I FURTHER CERTIFY THAT. , ‘ Dae ee Aa Ree HAS COMPLETED AND ATTENDED FOR 5 ___ ACADEMIC YEARS OF INSTRUCTION, WOMBER OF NOT LESS THAN THIRTY TWO WEEKS IN EACH ACADEMIC YEAR AT:_University of California, San Francisco NAME OF MEDICAL SCHOOL a CONTINUED_ON BACK OF THIS PAGE“-T0 MEDICAL SCHOO! Commonwealth of Massachusetts /MITED Board of Registration in Medicine Ten West Street -~ Boston, Massachusetts 02111 (617) 727-3086 FORM F ContINvED ‘An Agency within the Executive Oca of Consumer Ata and Business Regulation NAME OF APPLICANT __Daniela Anne Carusi Give exact dates of-instruction, including month, of month and year for each year to show the number of weeks, excluding vacations, in each year. FROMY 08 07 92 DAY TERR ONT DAY FROM: _09 o1 93 __T0:_06 30. 94 ‘MONTH DAY YEAR Nonte DAY YEAR FROM: _07 ou 94 To: vy YEAR Row: F YEAR FROM: _07 or 95 __TO:_06 30 96 NONTH “DAY ""YEAR- HONTHT Da’ FROM:_07 OL 96__T0:_06 og See NoNTH DAY YEAR NONTH DaY Wi FROM: TO: HONTH DAY "YEAR HONTH DAY YEAR FROM: On NORTH BaY vex" *poRTT DAY YEAR AND HAS RECEIVED/WILL RECEIVE A DEGREEE OF Medical Doctor ON___gune 8 19_97 . Lace We CQL we. SIGNATURE OF DEAN OR DESIGNATED OFFICIAL Emili Wi Osby M.D., Associate Dean AND TITLE (PLEASE TYPE OR PRINT) SCHOOL SEAL DATE:_April 25, 1997ie Application #: 7 9-5SRO2-Cl Date Approved /-1Y 7 9 Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street, Third Floor, Boston, Massachusetts 02112 He RENEWAL APPLICATION - LIMITED LICENSE IMPORTANT: Please read the accompanying instructions before completing this form, and print legibly ce ype your answers SECTION A: Sections A and C on page 2 are tobe completed by applicant. 1. Name: (Last) _CAOiAS | (Firs) DAWIELA (y__4. Telephone 2. Mailing Address:_ —— Number, City, State and Zip. ‘Name of Training Hospital: R&i Cathet =< COsueuls tos piraic Current Limited License Number: _¢ 2 502-99. 5. Other states (abbrevi TOR 1. .) where you are now fully licensed to practice medicine: Has the physician been subject to past or pending disciplinary action in this program? O Yes £7. No | hereby certify that the above-named physiciay i . Print Name: FR ADSRB IO pae_ 42,97 Signature of Program Director: Te : 232426) SECTION B: TO BE COMPLETED AND SIGNED BY THE DESIGNATED OFFICIAL OF THE INSTITUTION AT WHICH THE APPLICANT HAS RECEIVED AN APPOINTMENT. This certifies that ) Aided fbi. hhas been appointed to the position of| [) Intem 7) Resident [9 Fellow Program Name: Facility: ¥ Beginning Date:_/ /olQ / G2 Anticipated Completion Date of Training: _/ _/ 920_/ 7 Is the program accredited by the ACGME: Yes [No If no, is there an approved ACGME in applicany/sspecialty? Yes [J No Designated Official: uv. ‘Telephone: g47.790-8540 _ ined ‘ey Shaym Vanner Designated Official’s Signature: Graduate Medical Education r ure. ad RonePage 203 NAME: Dawe A CAR AS} SECTION C: Read the instructions. Check either YES or NO to each question. Do not answer N/A. Ifyou answer YES to any of these questions, you must provide details on Limited Supplement attached. XES NO SINCE YOUR LAST RENEWAL 16. Have you been granted a leave of absence or withdrawn from a post-graduate training program 17, Have you been denied the privilege of taking or finishing an examination or have you been accused of cheating or improper conduct during an examination? 18. Have you, for any reason, been denied a medical license, whether full, limited or ‘or temporary or have you withdrawn an application for medical licensure? 19. Have you voluntarily surrendered a license to practice medicine or any healing art? 20. Are any formal disciplinary charges pending against you, or do you have knowledge of any pending investigation into your professional competence or conduct by any governmental authority, by any hospital or health care facility, or by any professional medical association (national, international, state or local)? 21. Has any disciplinary action (see definition) been taken against you by any governmental authority, by any hospital or health care facility, or by any professional medical association (international, national, state or local)? 22. Have you been denied medical staff membership, or advancement in medical staff status, or has such denial been recommended by a standing medical staff committee or governing body? 23. Have you, for any reason, withdrawn an application for hospital privileges or appointment? 24. Have you voluntarily relinquished medical staff membership? 25. Has your medical staff membership, medical privileges or medical staff status at any hospital ‘been limited, suspended, revoked, not renewed or subject to probationary conditions or has processing toward any of those ends been instituted or recommended by a medical staff ‘commitiee or governing board? 26. Have you been charged with any criminal offense, other than a minor traffic offense? 27. Haas your privilege to possess, dispense or prescribe controlled substances been restricted, revoked, denied or surrendered, ot have you been called before or warned by this state ‘or any other jurisdiction including a federal agency regarding such privileges? 28. Has any medical malpractice claim been made against you (whether or not a lawsuit was filed in relation to the clairn)? 29, Has any lawsuit, other than a medical malpractice suit, which is related to your competency to to practice medicine, or your professional conduct in the practice of medicine, been filed against you or has such a suit been settied, adjudicated or otherwis: resolved?cea Lip® Q]-5302-99 Commonwealth of Massachusetts Board of Registration in Medicine 10 West Street, Boston, Massachusetts 02111 INITIAL LIMITED LICENSE APPLICATION IMPORTANT: Read the accompanying instructions before completing this form, and print legibly or type your answers. Please attach « $50 check payable to the Commonwealth of Massachusetts. CHECK ONE: [Graduate of a Medical School in the United States, Canada, or Puerto Rico (USMG) Graduate of an International Medical Schoo! (MG) 0) Graduate of an International Medical Schoo! applying under the Special Refugee Physician Program NOTE: GRADUATES OF INTERNATIONAL MEDICAL SCHOOLS MUST COMPLETE ADDITIONAL FORMS. SECTION A: Sworn Statement to be Completed by Applicant 1A. Name: Last)_( 4g! irs) _D4An GLa on_A_ 1B. OtherName(s) YES NO 1) Have you ever boen known under a different name or combination ofnames? =] 2) Have you ever been licensed under a different name? og 3) Have you ever applied for licensure, or applied to sit for an examination, ortaken 4in examination under a different name? Ifyes, you must provide additional information. (See instructions.) 2 Current Residence: _ Telephone Number- 3. Date of Birth (Mo/Da/¥1): race of Birth: Mourn) Views, CA 4. Sex: Male Female _X 5. Social Security Number; ~ 6. Name and address of Massachusetts Training Hospital: Berghe aoe Alon tens. 5, :10. i 12. 13. Page2 of 6 Location: San) FRavicusco, LACIE ealis, ISA ae ‘Year of Graduation _)49 7 Degree Received: M.D. [&] D. O. [) Other (specify), Have you had previous post-graduate training? Yes] NofQ U.S.C Intemational (] ‘Name of Institution: Address: Name of Program: (ifadditional space is needed, please continue your answer on a separate sheet Of paper) List states (abbreviations) where you are currently licensed to practice medicine: List states (abbreviations) where you were previously licensed to practice medicine (include residency training licenses): Medical School Training: YES NO a) Ifyou are a USMG, have you taken more than 4 years to complete medical school? b) If you are an IMG, have you taken more than 6 years to complete medical school? Ifyes, you must provide additional information. (See instructions.) Has more than one year passed between the date of your graduation from medical ‘school and the anticipated start date of your limited licensure in Massachusetts? If yes, you must provide additional information. (See instructions.)Page’ of 6 NAME DAniana Cavuisy XES NO 14, Have you ever been enrolled in a residency training program(s) that you did not complete? Ef yes, a letter from your program director is required. (ee instructions.) Explanation attached? Program Director's Certification requested? SECTION B: Read the instructions. Check either YES or NO to each question. Do not auswer ‘NA. If you answer YES to any of these questions, you must provide details on the Limited License Supplement. YES NO 15, Since your matriculation in college, have you been subject to any disciplinary action (see definition) at any academic institution? 16. Have you ever been terminated or granted a leave of absence by a medical school or medical post-graduate training program or have you ever withdrawn, from a medical school or medical post-graduate training program? 17. Since your matriculation in college, have you been denied the privilege of taking or finishing an examination or have you been accused of cheating and/or improper conduct during an examination? 18. Have you ever, for any reason, been denied a medical license, whether full, limited or temporary, or have you withdrawn an application for medical licensure? 19. Have you ever voluntarily surrendered a license to practice medicine or any healing art? 20. Are any formal disciplinary charges pending against you, or do you have knowledge of any pending investigation into your professional competence or conduct by any governmental authority, by any hospital or heaith care facility, or by any professional medical association (international, national, state or local)?Page 4 of 6 NAMB: DANG Ac CARuSI 21. 22. 23. 27. 29. YES NO Has any disciplinary action (see definition) ever been taken against you by any governmental authority, by any hospital or health care facility, or by any professional ‘medical association (international, national, state or local)? Have you ever been denied medical staff membership, or advancement in medical staff status, or has such denial been recommended by a standing medical staff committee or ‘governing body? Have you ever, for any reason, withdrawn an application for hospital privileges or appointment? Have you ever voluntarily relinquished medical staff membership? Has your medical staff membership, medical privileges or medical staff status at any hospital been limited, suspended, revoked, not renewed or subject to probationary conditions or has processing toward any of those ends been instituted or recommended by a medical staff committee or governing board? Have you ever been charged with any criminal offense, other than a minor traffic offense? Has your privilege to possess, dispense or prescribe controlled substances ever been suspended, revoked, denied, restricted or surrendered, or have you ever been called before or warned by any state or other jurisdiction including a federal agency regarding such privileges? In the past ten (10) years, has any medical malpractice claim been made against you, whether or not a lawsuit was filed in relation to the claim? In the past ten (10) years, has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your professional conduct in the practice of medicine, been filed against you or has such a suit been settled, adjudicated or otherwise resolved?Page sof NAME: D4nicua CAeus SECTION C: TO BE COMPLETED AND SIGNED BY THE DESIGNATED OFFICIAL OF THE INSTITUTION AT WHICH THE APPLICANT HAS RECEIVED AN APPOINTMENT. ‘This certifies that Danian A. Canusi, MD has been appointed (Name of Applicant) to the position of [] Intem Resident [} Fellow in the, Obstetrics | Guneco: 2au ‘(Name of Program) at BRIGHAM & WOMEN'S HOSPITAL ‘Came of Hospital) beginning _@-/ BO /G"1 toanticipated completion of training: __@ /.3.O /O\ . (Gate) 7 (date) YES NO Is the program accredited by the ACGME? wo If mo, is there an ACGME. approved training program in licant’s specialty? Designated Official’s Signature: VW R. Wane Type or Print Name and Title: Shawn Vanner Program Administrator Dae:_S/ 5/97 ‘Telephone Number: 617-732-8540 eharormsntinape? 22897)ats SUPPLEMENT FORM Name Danitla oe IMPORTANT NOTE: if you answer “yes” to any of these questions, you must provide the additional information on pages 4-10. 1. Since your enrollment in college, have you been subject to any disciplinary action (see definition) at an academic institution?” 2. Have you ever been terminated or granted a leave of absence by a medical school or medical post-graduate training program or have you ever withdrawn from a medical school or ‘medical postgraduate training program or had to repeat a year of postgraduate training? 3. Have you ever applied for licensure or to sit for an examination or taken an examination under a different name? If s0, previous name: 4, Since your enrollment in college, have you been denied the privilege of taking or finishing ‘an examination or been accused of cheating and/or improper conduct during an examination? 5S. Have you ever failed any of the following examinations: FLEX, any State Board ‘examination, any part of the National Boards, any Step of the USMLE, or have you failed to gain certification from the National Board of Medical Examiners or any foreign licensing or certification body? 6-A. Have you ever, for any reason, been denied a medical license, whether full, limited, temporary, or have you withdrawn an application for medical legasure?.—.... . 6-B. Have you ever voluntarily surrendered a license to practice medicine or any healing art? 7. Have you ever, for any reason, lost American Board of Medical Specialty certification ‘or been denied required recertification by one or more specialty boards? 8A. _Areany formal disciplinary charges pending against you, or do you have knowledge of any pending investigation into your professional competence or conduct by any governmental authority, health care facility, group practice or professional medical society or association (international, national, state or local)? (See definition). 8B. Has any disciplinary action ever been taken against you for violation of laws, rules, by-laws, or standards of practice by any governmental authority, healthcare facility, group or professional medical society or association ( national, state or local)? YES NO Page 19-A. 9-B. 9c. 10, 2, 14, 15-4. 15-B, Have you ever voluntarily relinquished any medical staff membership? = =~ ‘Has your medical stafT membership, medical privileges or medical staff status at any hospital been limited, suspended, revoked, not renewed or subject to probationary conditions or has processing toward any of those ends been instituted or recommended by a medical staff commnittee or governing board?” Have you ever been denied medical staff membership, or advancement in medical staff status, or has such denial been recommended by a standing medical staff committee or governing body? Have you ever, for any reason, withdrawn an application for hospital privileges or appointment? Have you ever been charged with any criminal offense, other than a minor traffic offense? Has your privilege to possess, dispense or prescribe controlled substances ever been suspended revoked, denied, restricted or surrendered, or have you ever been called before or warned by any state or other jurisdiction including a federal agency regarding such privileges? Has any professional liability insurance provider ever restricted, limited, terminated, imposed « surcharge or co-payment, or placed any condition related to professional competency or ‘conduct on your coverage or have you ever voluntarily restricted, limited or terminated your insurance coverage in response to any inquiry by a professional liability insurance provider? Have you ever been the subject of any suspension or probation proceedings instituted by Blue Cross and/or Blue Shield, Medicare, Medieaid; or any other medical Reimbursement plan; or have you ever been restricted from receiving payments from any Blue Cross and Blue Shield, Medicare, Medicaid (any state), or third party programs? Have you ever had an application for membership as a participating provider rejected by any HMO/PPO/IPA ot other prepaid health care plan or your contract as a participating provider terminated by any HMO/PPO/IPA or other prepaid plan? In the past ten (10) years, has any medical malpractice claim been made against you, whether ‘or not a lawsuit was filed in relation to the claim? In the past ten (10) years, has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your professional conduct in the practice of medicine, been filed against you or has such a suit been settled, adjudicated or otherwise resolved? Applicant's Signature:_AA Leailh (ae Date:_W)_Uf) 6d Page 2Commonwealth of Massachusetts~Board of Registration in Medicine 10 Wet Stet, 3a Floor, Boston, MA QZITL (617) 727.086 E race POSTGRADUATE TRAINING VERIFICATION ] s28ibars AORZATON ‘une ypu wanton ngewe vow Ms Region edie. ° whe (ar Lilac 6 Signature: lew} Type Name: SS hae br insotuto: “a's, Pease complet bs form ad forward Kt the Board or Registration fh Medicne atthe adress above, Ith dopartmant was aYlatng or “vanelonat ‘rogram. pease submit documentaton ofthe retafons, datas anc hours of taining othe Board. Name tosuson Bethan end Nosen's-Nospitsi-tacsachvactis Gentrél Hospice: integeatadtiésidency Traising trogen a Obstetcicy and Gynecoleny are ctnstuton was reat when pecan stones, lst rer name . ‘Ewolment ane Fanepstion: Ourecos nda et ante. carat im _____pantopatacintfotoug progam: ee = cau Dates Aten Teena oy amano, | roy | cosbimrs woos aay comptes | nee nsernbaor {allowahip) (1284) | medic, ot) | royy To: (VESNO) | "not scored Residency 7 ae 6 _t20 4sr Ls !30 fo |e cose ae erat ta nt 1a las acct Residency ri Db, ry be f bo foo }yes ACHE 1 Aestdens 4 wa ta bce | REE sce ia io | | [ Continued on back mowrane Dewitle (aus ________. || mana Grcumatanent Te fon eons ay onl carne tat ocd hy apa ofthe apc cl eat, Pee i prt etpancs yeu anavor ye oan of thee quent, pave win repanton QUESTIONS | | ves No 1 baetatiemrmanstalieeatestotibesmtgninitant |) 2 Was ta appear oe pacedon pet ; 2. Wt apple ve dpe a fer venga? i 4 vm ne prs ve ey ster gpa ean i 5 Yo ny no sn arc nt pnt bc nin tne ‘i | : 6, burg tne appenrspakcson,curfosraale medal ining (Gas acces by GY ACGME (Ober COMMENTS T Certain: hereby cry athe aie efomaton comet othe best of my Inoue arrxwsriiin (tt toa imatitutlon does cit haye'a sea. otras) Peeem ffm " ¢ etd MiaeaeHy Board of Registration in Medicine Nh ote ace ae jston, MA 02111. (617) 727-3086 Waiver for Release of Information | auterize the mecica!schoatuniversty stad below to prove ony ap al information pertaining to my mada eaucaion al your insitan othe ‘Massachusetts Board of Registra Aopleant's Sinatie: Date of Bin PrintorType Neme:____C#eu8i Damier A_ Social Security No. Taran) when Tanabe tah Other Nemats) (Piase peo patna Name of Macical Scho! = CA Fenn, waees Elite § Seale Abbas SDE esas by Sau Exceica_Samerrovece CA ‘oon ee INSTRUCTIONS TO THE DEAN.OR DESIGNATED OFFICIAL OF MEDICAL SCHOOL Please complote this form and forward lt, together with 2 copy ofthe applicant's official trancript (which indicates courses taken, tas and hours of aiondance, and scores, graves, of evaluations} directly tothe Board of Rogitation in Moacine. APPLIGANT’S EDUCATIONAL HISTORY. name of instiuson was diferent om the above named insiluion when eppican llendex, please enter nene below: Promedical Education: Does your school have a premedical school education equrement? fk} Yee [J No tyes, nceate where the applicant completed premedcal schoo, ‘Aoplcant’s Undergaduate Schoo: University of California Log Angeles Underpredusi School Adéross: Los Angeles, CA —— Coininn oe barkEnrolinent and Participation: Our cecorés indist hat : t a a a tended our mascl schol onthe flowing date (dicate the month, day and yearin he secon blow} ATIENDANCE DATES: FROM ) To ‘FROM mo fe 97132 As t93 or) a 195° 6 /_301.96 x poryss AE 3a 36 sage nara 38 To faa Far oa 7 oi 34 "06/30/35. ‘The eppicatatiendod 31-40 weeks of continuing on-campus esueation, nates than 32 weeks nach academe yearend chackona — [Ki was awarded a deglee In_ Medicine __on (montvéayiyear) 96 og 97 C was oT awarded degree, ats emi 1 ‘Unusual Circumstances: The ofowing queséns spply to unusual crcumstances tht occutted Guting any. of te applicants media! education, Al spoctone must be srewore YES ‘NO 1. Die epcant the any eaves of absence fr aot torn isher made edvnton? 2. Whos he mpeart ever piscad on probation? 4. ios eon aver dcr’ ouner esa? 4. here any nga eps evr ey inners eaprng the oon? COMMENTS: z i sen ee ‘Signature: Vawiv Lyathlo (th in seal, eto litbe noes) PintName: Maxine Papadaksb, MD sermon ueoefl actos ber arracna seoelae nae COPY OF THE MEDICAL SCHOOL DIPLOMA ANA Tt-A8sociate De i TRANSCRIPT OR PROVIDE AN EXPLANATION. pees a atage tage ct 7 “Thank you for completing this form,Massachusetts Physician Renewal Application License Nos _209287 Physician Name: Daniela A Carusi, M.D. PARTA 1) Current Status: Active Renewal Due Date: 06/25/2007 Birth Date: Ifyou want to change your current status, please check ane ofthe following boxes to indicate your new status: ‘Check only one: (See Renewal Instructions, page 3.) Active G Retiring Di tractive Do not wish to renew 2) Addresses & Contact Information. Please confirm your addresses and make changes, i necessary. You are required to notify the Board of Registration ia Medicine within 30 days of any change of address. Home and Business addresses CANNOT be a Post Office Box. 2a) MAILING ADDRESS. 1D. Check here to change this address RECEIVED 20) HOME ADDRESS. way 14 2007 Boats of Registration in Medicine Phone: 1 Cec hereto chong tare 2¢) BUSINESS ADDRESS Brigham & Women's Hospital 15 Francis St Boston, MA 02115 Phone: (617)732-5452 1D hector to change thi address, 3) E-mail Address: 4) Fax Number: _(617)232.6346 Please make corrections (print) County: Home Telephone: ( State: Home address cannot be a Post Office Box Business Address: City/Town: Zip: Country: Business Telephone: (_). State: Business adévess cannot be a Post Office Box ‘Correct your E-mail and Fax Number below: '5) Specialties (See Renewal Instructions, page 4) Delete? List Additional Specialties: Obstetrics and Gynecology o a a © Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Informatie (Gee enclosed instructions and Renewal Instructions, page 4.) List Certifying Board(s) below: Update General Certificates and Subspecialty Certificat below. Please add additional Cerifieations as required. Board Name ABMS or AOA CertificaterSubspecilty Delete? Obstetrics & Gynecology ‘ABMS Obstetrics and Gynecology o a a a Page 1 of 9 a oMassachusetts Physician Renewal Application Physician Name: Daniela A Carusi, M.D, License No.: 209287 (Gee Renewal Instructions, page 4) Please make corrections as necessary 7) Drug License Numbers 8) Other states where you are now licensed to practice 12) Massachusets: foe ee eee ) Federal (DEA): 9) States where you were previously leensed ©) Federal (DEA) XS: 10) List all work sites in Massachusetts, including health care facilities (where you are credentialed), private offices, clinics, nursing homes, etc. For the names of the health care facilities, refer to Reference Table 4 on page 18 of the Renewal Instruction booklet, Include any affiliations with Internet-based prescribing services ‘or companies. Please provide all information om all work sites, attaching a separate sheet, if necessary. Tint the names ofall work aes in Massachusetts Tacation State | pete? (See above and description on page 4.) (City or Town) ‘Brigham & Women's Hospital Boston Ma a o a a o 11) Care of patients in Massachusetts (See Renewal Instructions, page 4.) Average weekly hours involved in: a) inpatient care 24 hrsiwk Change to: hrs/wk b) outpatient care 24 hreiwk Change to: hrshvk 12) Medical Liability Insurance Information (ge Renewal Insructions. page 5) ‘Cheek one. Locum tenens must lis policy dates, My medical liability insurance is provided through: DB tusurance Carrier (complete below) ‘Current Insurance Cartier: CRICO Change to: Policy dates: From _.// /2%% — Yo_1a/3! / 200% ‘Type ofPoticy: C1 Claims made with tail coverage BY Occurrence Policy (Enclose a copy of the certificate of insurance or the face sheet) 1 Later of Cre subject 9 Board approval (Attach copy.) i Lam registering with Active status but am not required fo have medical lability insurance Because 1 Checkone: C1 Norinvolved wit director indirect patient care in Massachusetts [A Goverament Employee under Federal Tort Chins Act FTCA) (ti C1 Otherwise exempt (Please explain). 13) Do you perform any surgery in your Massachusetts office? (Sze Renewal Instructions, page S,) Yes No Yes, please complete Form PCA-O "Office Based Surgery’ Form on page 8. Page 2 0f 9 aMassachusetts Physician Renewal Application Physician Name: Daniela A Carusi, M.D. License No.: 209287 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. (See Renewal Insiructlons, page $,) ‘You must check either YES ot NO to each question, Provide details on Eon R if you answer “VES” to any questions. Refer to Renewal Instructions for additional information and definitions. YES NO ———___—— 14) CLAIMS MADE io 4) NEW: Fave you received notification of a clair, whether or not a lawsuit was fled on that claim, or has any medical malpractice claim been made against you during this time period? (see above). b) PENDING: Are there any unresolved malpractice claims against you today, ic, any claims that have not been finally setled or finally adjudicated? 15) CLAIMS CLOSED Has any medical malpractice claim against you (whether or nota lawsuit was filed on that claim) been resolved, setled, or adjudicated during this time period? 16) OTHER CIVIL LAWSUITS Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. a) New: Have there been any claims, other than medical malpractice claims, filed against you during this time period? ') Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during this time period? 17) CRIMINAL CHARGES «) Have you been charged with any criminal offense during this time period? 'b) Have any criminal offenses/charges against you been resolved during this time period?” ©) Are there any criminal charges ponding against you today’? 4) Are any Applications for Issuance of Process pending against you? 18) INVESTIGATIONS AND DISCIPLINARY ACTIONS 2) Have you withdravm an application to any governmental authority, health care fciliy, group practice, ‘employer or professionel association? 'b) Have you ever taken a leave of absenes from any health care facility, group practice or employer? 6) Have you been the subject ofan investigation by any governmental authority, health care facility, group practice, employer or profesional association? 4 Have you been the subject of dseiplinay action taken by any governmental authority, health care facility, group practice, employer or profesional association? 19) Have your privileges to possess, dispense or prescribe conzlled substances been suspended revoked, denied, restricted by, or surrendered to any state or federal agency? 720) Have you withdrawn an application for a medical license, allowed a license application to become obsolete ‘orhave you been denied a medical license for any reason? 4. 7) Has ny medial ability osurance carer eoticted, lined, erminted, imposed a surcharge or related to professicnal competency or conduct on you coverege, or ed oreminated your insurance coverage in tespnse fan ty by amedical liability insurance carrier? 72) CME CERTIFICATION: 1) Have you completed your CME requirements preceding you ecewal dae? Yes [] No 1) ff no, are you requesting « CME waiver? Cvs (No ACME waiver request form must be submited at leat 30 days prior to your license expiration date. ©) Ifyou are exempt from CME requirements, check reason for exemption, (See Renewal instructions, page 8.) CME EXEMPTION: (check one) CI Inactive Satus CI. ResdencyFellowship rang Page 3 of 9