Azatiaione, AOA Date of lsue: REDACTED COPY card ‘registration in Medicine Commonwealth of Massachusetts - Board of Registraton in Medicine 560 Harrison Avenue, Suite #G4, Boston, MA 02128 (617) 654-9810 - www.massmedborrd.org, L. {CATION ade payable to the Commonwealth of ™ ‘Massachuseits Cheek Ones PE s.canasian Graduate 1 nemationat Graduate ‘Legal Name (do not use nicknames or initials, unless they are part of your legal nme) GRACE ast Name (type or pnt clearly), first Midlie Sufix Ure) $Ki00.0 p00 Php O otkerdegee Male Female ‘Quer Name(s) Used - List any other name(s) you have used wich may appearon your identifying document, such 4s medical education and examination records (not epplicable, check here é CE Batice Last Name (type or print clearly) First Middie Safi Gree) Date of Biche Sovist Security Numbers _ ‘Monik Day Year nse oft. DEFIANCE Azo StavelProvince/Tenitory Country iraot USA Hlome Address, Sumber and Set ~ City ‘State/Province/Territory, Zip (or postal) Code Busines Adres : ‘Wamber and Stree Boston MA O25, Ciy Sat ProvinerFerery “ip (orpowal Code Business jt Home Taopaons, Cl) 82 Cle ox, SHEP Teerhone: _ Preferred Mi ‘Address: CJ fusiness Address PRC Home Addtessvuntname Alice 6. manid PAGE 20F3 Ree-medical Schoo} P ke Pecility_Swaxth mere Cot » Bk O70, 780) 1994 See et oe pant bas BI Facility: _—-_ Degree: Street: City: Maia Scho} ‘ Seu akat fac Colar FiS gg —— rome ap UU AE AE RR Sweet: City: MYC State: AY Facility:. a egre Street: City, States Date of medical school graduation, OS 180} 1997 ‘Nowe: 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 longer than six (6) years and any breaks in medical education, Postgraduate Edueation: List all postgraduate training in chronological order from medical school tothe present. Include the name and address of the facility, your position, e.g. PGY 1, 2, fellow, ete. and dates of affiliation, You must account for all, periods of training or postgraduate work from the time you graduated from medical school, Eom To Facility: Bigham ¢ Wenan's Hoepi ted Position: AY IY Ob/20/F] 06/20/05 Street: 20 “faaacis — Ciy: Aosta —___Statenogt_ Facility: Position: IM Oe/2022 Cleid0/03 Sree 8 Fak ot ity: State: Date Facility: Position: Street, ety Position: City: Position: City: Si menace heman nave: Arte G. Maree. racnsors Hospi tons and Empl List hospital appointments, in chronological order, where you had active staff privileges. Include the name and addcess ofthe facility, your postion andl dates of affiliation. Also include periods of unemployment or employment outside of medicine. Attach e separate sheet of paper if necessary. From Ip Facility: Bri : s Position _Regiakt % 20) 94 620/03 See Cry Beebe Sa Lan Eucility: ewe eS position; epider+ 120/91 6 20/08 Street Finait St City: Basin State: af Facility: Pos Street: City: Facility Position: JI Strect: City State 1. List other states (abbreviations) where you are currently or have ever been licensed: _" 2. Aro you certified by the American Board of Medical Speciaites? ) Yex2X No 3. List Board Certification(s): Certification date f_/_ Cemtfication date:_/. 4, Have you attached an up-to-date copy of your curicutum vitae?” DR“ Yeo () No 5, Reason for zequestng a Massechusets medical lense 1asso 5 : 6. Name of tasty: Grighaa ond bien se's Hpspiled CO _ 1 Address: 20 Famers Sr city, Bosh 8, Anticipated starting date in Massachusetts: _ 12003 __8/3]/03 Date(CURRICULUM VITAE Part I: General Information Date Prepared: Home Address: Phone: BMal: Place of Birth: Education: 190.1994 1995-1999 Experience: 1994-1995 1995 1999 Postdoctoral Tralab 1999. present Licensure: 1999. present Langua March 3, 2003 Alice G, Mark, M.D. Brigham and Women's Hospital Department of Ob/Gyn 75 Francis Strcet Boston, MA 02125 Fort Defiance, Arizona B.A, Religion, Swarthmore College, Swarthmore PA, M.D., Columbia University Colloge of Physicians & Surgeons, New York, NY. ‘Teacher, English as « Second Language, Ghana Intemational School, Accra, Chana Intern, National Health Service Comps, Plan de Salud del Valle, Frederick, Colorado. Fellow, Center for the Study of Society and Medicine, Luise Guidolti Hospital, Mutoko, Zimbabwe, Intern and Resident, Obstetrics & Gynecology, Brigham and Women's Hospital’ Mastachusetts General Hospital, Boston MA, Massachusetts Limited License Fluent Spanish, intermediate French. Alice G. Mark Page 1 2S GEES;Awards and Honors: 1994 B.A. magna cum laude, Swarthmore College 1994 Phi Beta Kapps, Swarthmore College 1999 Fellowship in Human Rights and Medicine, Columbia University 1999 Alpi Omega Alpha, Columbia University 2002 Resident Teaching Award, Harvard Medical School Part Ui: Researeh, Teaching and Ctinteal Contributions Report of Presentations: Jan 2001 Reducing the risk of multiple gestation in ART. Brigham and Women's Hospital Grand Rounds, Advisor: Mark Hornstein, MD Jul 2001 Recurrent pregnancy loss. North Shore Medical Center / Salem Hospital Grand Rounds. ‘Advisor: Joe Ti, M.D. Sep 2001 Medica! therapy for female sexval dysfunction, Brigham and Women’s Hospital Grand Rounds. Advisor: Jén Shiften, M.D. Jun 2002 Day 6 estadiol as predictor of IVF suooees. Brigham and Women’s Hospital Resident Research Day. Advisor: Elizabeth Ginsburg, M.D. Jan 2003 Second trimester abortions: a search for solutions. Brigham and Women's Hospital Grand Rounds. Part I: Bibliography Original Articles: ‘Mark AG, Shifren J. Medical therapy for female sexual dysfunction, Prim Care Update Ob/Gyns 2003; 10(1)40-43, Abstracts: Mark AG, Racowsky C, Jackson KV. Does time of year impact clinical outcomes in IVF? Poster presentation, ASRM, 2002, Mark AG, Ginsburg ES, Jackson KV, Walsh BW, Racowsky C, Maximizing outcomes for poor responders to controlled ovarian hyperstimulation in IVF: the use of microdose flare GnRH agonist {induction to gonadotropin stimulation in wotnen with previous IVF faiture. Festi Steril 2001; 76(3): $231 Poster presentation, ASRM, 2001 Greenberg J, Economy X, Mark A, Ringer 8. In search of “trao” bith asphyaia: labor characteristics associated with the sgphyxiated term infant. Am J Obstet Gynecol 2001; 185(6}:294, Oral presentation (Dr. Heonomy), SMM, 2002, Alice G. Mark Page 2ASAE Application #:_Q9~ 29 1 ~ 03° Z Date Approved: 7. ~ Commonwealth of Massachusetts Board of Registration in Medicine 10 West Street, Boston, Massachusetts 02111 Fate Q ae INITIAL LIMITED LICENSE APPLICATION _] IMPORTANT: Read the accompanying instructions before completing this form, and oF (Pe your answers, Please attach a $50 check payable to the Commonwealth of Masiachusetts, CHECK ONE: Graduate of a Medical Schoo! inthe United States, Canada, or Puerto Rico (USMG) Graduate of an Intemational Medical School (IMG) : Graduate of an International Medical School 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 i I-A. Name: (Last)_Sonpre-iner (First)_Avice MG 1-B. Other Name(s): a eeeeeSesSeSeeSFSsSeF ¥Es NO }) Have you ever been known under a different name or combination of names? 2) Have you ever been licensed under a different name? 3) Have you ever applied for licensure, or applied to sit for an examination, or 1 ‘taken an examination under a different name? ‘fyes, you must provide additional information, (Gee instructions.) 2 Cument Residence: Telephone Numbers State: _ City. 3. Dateof Birth: lace of Birth: EY z 4. Sex: CMae. pa Female 5. Social Security Number: 6. Name of Massachusetts Training Hospital: Bagram é wowew's thseNAME: _Auce Sombyeimen— Page 2 0f6. 7, Name of premedical school(s): SaeDINORE oeoe Location:_SwACTHMoe pa, us Ci Ta Caaay 8 Name of medical school(s): _Couumara COWEGE of PHYSICIANS 3 SunGecoNs Wife! Vocatne NY Ae} _uSA ‘Year of Graduation: 4% __ Degree Received: SYM. D. (C] DO. Other(specify) 9. Have you had previous post-graduate training? >EINo C1y¥es = [U-S. or [7 Intemational ‘Name of Institution; Address: Name of Program: Dates of Training, (Of adiional space is needed, please continue your answer ona separa thet of paper) 10. List states (abbreviations) where you are currently licensed to practice medicine (include residency training licenses): Nee i List states (abbreviations) where you were previously licensed to practice medicine (include i 8): residency training licenses): Rows 12. Medical School Training: YES NO 8) If you are a USMG, have you taken more than 4 years to complete medical school? b) Ifyou are an IMG, have you taken more than § years to complete medical school? Ifyes, you must provide additional information. (See instructions.) 13. 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? ‘Ifyes, you must provide additional information. (See instructions.) mA ps omNAME:__fuce Sonpie mest Page 3 of 6, YES NO 14-A. Have you ever been enrolled in a residency program(s) where you were required to repeat a year of training? (See instructions). 14-B, Have you ever been enrolled in a residency training program(s) that you did ‘not complete, or where you transferred to ‘another program, specialty or facility? Tf you answered “yes” to question 14-A or 14-B, a letter from your Program director is required. Explanation attached: [7] Program Director’s explanation requested: [~] SECTION B: Read the instructions. Check either YES or NO to each question. Do not answer N/A. If you answer YES to any of these questions, you must provide details on the Limited License Supplement. YES NO 15, so Your enrollment 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 enrollment 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, health care facility, group practice or professional medical society or association (intemational, national, state or local)? (See definition).NAME:_AvIcE somo mir. Page 4 of 6 21. 24. 26. 27, 28. 29, XES NO 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 bospital 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 govemning board? Have you ever been charged with any criminal offensé, other than a minor traffic offense? Has your privilege to possess, dispense or prescribe controlled substances ever been suspended, revoked, denied, restricted or surrenciered, or have you ever been called before or warned by any state or other jurisdiction including a federal agency regarding such privileges? mn 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 lawauit, 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 aguinst you or has such a suit been settled, adjudicated or otherwise resolved?NAME:_4ce. SoNDHE i Mer— Page bor 6 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 _ ice. Sondheimer hhas been appointed (Name of Applicant) ‘otheposition of [J Infem ff) Resident Fellow Ob 5) in the specialty of. asaPGY Faq BRIGHAM & WOMEN'S HOSPITAL ‘(Name of Hospital) beginning_© / 0 QQ, to anticipated completion of taining: _@ (36/03, month day yer ‘month day ‘Year XES NO Is the program accredited by the ACGME? wa Tf no, is there an ACGME-approved training inthe appligam’s speciaty? 1] somone — Lan Vig ‘Type or Print Name: Shawn Vanner, Manager Graduate Medical Saucer ——————— Official Title: 7 6 . bee SOT, _ RO re ‘Sharam nap? fo. 0172289gf to a Int a ft ho cue SF Date Approved: Commonveaith ot Miaka Sbacetts- Board of Registration in Medicine i Ten West Street, Third Floor, Boston, Massachusetts 02111 ' RENEWAL APPLICATION - LIMITED LICENSE BOARD OF REGISTRATION EDIE 1, Name: (Last) Somouermen (irs) Arce (m0) _G . Telephone 2. Mailing Address:_ - Number City: State: Zip: 3. Name of Training Hospital: BRiGH#M > WloMEN'S 4. Current Limited License Number: _ 99~ 9211-03, 5. Other states (abbreviations) where you are now licensed to practice medicine, Indicate whether full license (F) or residency ot training license (L). __ Le) La.) Oe Ow Oe Da SECTION B: To be completed by program director, Has the physician been subject to past or pending disciplinary action in this program? Yes [No Thereby certify that the above-named physiciaw is in good standing in the training program. Print Name: pate_3 4) 20 Telephone: GIF 232 420 os To be completed and signed by the designated official of the institution at which the applicant has | received an appointment, This denites at_ 9 6c Saelharmee_hasreon appointed tines to the position of [4 Inigm [XM Resident (J Fellow as a PGY. Z. Hospital Name: ber Ghom bdnncdis tcf. Specialty: Bi Cyn Beginning Date: ALS /_ Gf Amticipated Completion Date of Training: 24) 30 , les Is the program accredited by the ACGME: Yes [J No : If no, is there an approved. ACGME program % applicant ABE Rager Yes [[] No Designated Official: Graduate Megical Education, telephone: 732 Yy22— Graken) Tis ; Designated Official's Signature: ate: 023 (G7 \GO. Signature of Program Director:NAME:_Sanpue ime AUCE G SECTION C: Read the instructions. Check either YES or NO to each question. Do not answer N/A. I you answer YES to any of these questions, you musi provide details om Limited Supplement attached. YES NO 1 TREN) Note: These questions apply only since your last renewal 16, Tne you been terminated, granted a leave of absence, withdrawn or had ta repeat a year in 4 postgraduattlivaining 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? 48 Have you, for any eason, been denied a medica license, whether fll, timited or or temporary or have you withdrawn an application for medical licensure? 19. Have you voluntarily surrendered a license to practice medicine or any heating art? 20, Are any formal disciplinary cherges pending against you, or do you have knowledge of any pending investigation into your professional competence or conduct by any governmental authority, health eare facility, group practice or professional medical society or association (international, netional, state or local)? (See definition), 21. Has any disciplinary action been taken against you for violation of laws, rles, by-laws or standards of practice by any governmental authority, health care facility, group practice. or Brofessional medical society or association (international, national, sate or local)? (Gee definition). 22, Have you been denied medical staff membership, or advancement in medical staff status, «has such denial been recommended by a standing medical staf commitice or governing body? 23. Have you, for any reason, withdrawn an application for hospital privileges ot sppointment? 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 probetionary conditions or has 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 a minor trafic 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 state or other jurisdiction including a federal agency regarding such privileges? 28 Has any medics! 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 i elated to your competency to Practice medicine, or your professional condut in the practice of medicine, been filed against ‘You oF has such a suit been settled, adjudicated or otherwise resolved?TE , Aes WR ~ 905 arpa, 420 core Date Approved: Ay / 12/87 so monwe Tees ff -[Board of Registration in Medicine who war Street, thd on ee oor, Boston, Massachusetts 02111 - www.massmedboard.org as SE RENEWAL APPLICATION - LIMITED LICENSE IMPORTANT: Picase rad the accompanying insinitions before completing this form, and print legibly or type your answers IONS “A” AND “C” ON PAGE 2 ARE TO BE COMPLETED BY APPLICANT, SECTION A: 1. Name: (Last) Magic : __First)__ Arce (Mn_G Telephone 2. Mailing Address; Number:_ City: State: _ Zip: _. 3. Name of Training Hospital: _ BW / Mad 4, Current Limited License Number: 949-Fail-o3 _ 5. Other states (abbreviations) where you are now licensed to practice medicine, Indicate whether full license (©) or residency or training license (L), __ Cy Tia) Om Gay Ow Oa) ‘o be sted by program director, Has the physician been subject to past or pending disciplinary action in this program? (Yes [3 No Thereby certify that the above-named physician is in good standing in the training program. Print Name: ber Date s2_ AB jo) Signature of Program Director. ‘Telephone: 617273224265 To be completed and signed by the designated official of the institution at which the applicant has received an appointment. This certifies that, eG. Mark, M.D. as been appointed ane Aan) tothe position of [} tntem (Mf Resident [] Fellow asaPGy_ Homi Ne Didar Gad Wweriars Haste! spiny OB (GI) Beginning Date:_{2_/ ZO/ 2 Anticipated Completion Date of Training: (2/30/03 Is the program accredited by the ACGME: Yes [] No fg, is there an approved ACGME program in applicant's specialty? Yes [] No Designated oni Yay (CES __ Telephone: (0! "132- Fly ore ) et Designated Official’s Signature: Date: SB) BjO/Page 2 of 3 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. THESE QUESTIONS APPLY ONLY SINCE YOUR LAST RENEWAL YES NO 16. Have you been terminated, granted a leave of absence, withdrawn or had to repeat a year in a postgraduate-training program? 17. Have you been denied the privilege of taking or finishing an examination or have you been bs accused of cheating and/or improper conduct during an examination? a 18. Have you, for any reason, been denied « medical license, whether full, limited or ‘or femporary or have you withdrawn an application for medical licensure? 19. Have you voluntarily surrendered @ license to practice medicine or any healing at? 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 goverimental authority, health care facility, group practice or professional medical socicty or association (international, national, state or local)? (See definition). 21. Has any disciplinary action been taken against you for violation of laws, rales, by-laws or standards of practice by any governmental 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 resson, 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 medica! staff committee or governing board? 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 wamed by any state 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 sui, 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?SUPPLEMENT FORM prntname: Alice @. Ane pares 3 303 Ifyou answer “yes” to any of these questions, you must provide the additional information on pages 4-10. QUESTIONS t BA. BB. Applicant's Signature: Since your enrollment in college, have you beon subject to any disciplinary action (see definition) at an academic institution? Haye you ever been terminated or grantod @ leave of absence by a medical school or medical ‘post-graduate trining program or have you ever withdrawn from a medical school or medieal postgraduate training program or had to repeat year of postgraduate training? Have you ever applied for licensure otto sit for an examination or taken an examination under a different name? If so, previous name: ———— ‘Since your enroliment in college, have you been denied the pivitege of taking or finishing an ‘examination or been accused of cheating and/or improper conduct duting an examination? Have you ever failed eny of the following examinations: FLEX, any State Board examination, ‘any part ofthe National Bosrds, any Step of the USMLB, NBOME, or have you failed to gain certification from the National Board of Medical Examiners or any foreign licensing ot certification body? Have you ever, for any reason, been denied a medical license, whether full, limited, temporary, ‘or have you withdrawn an application for medical licensure? Have you ever voluntarily surrendered @ license to practice medicine or any healing art? Have you ever, for any reason, lost American Board of Medical Specialty or been denied Tequited recertification by ane or more specialty boards? ‘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 ‘uthority, bealth care facility, group practve or professional medical society oF association (international, national, state or local)? (See definition), ‘as any disciplinary standards of practice medial society or Wy governmental authority, healthcare facility, group or professional (national, state oF Socal)? ep ever beon taken against you for violation of laws, rules, by-laws, or XES NO9A. 9-8, 90, oD. 10, ISA. 15-8. Applicant's Signature: YES NO ‘Have you ever voluntarily relinquished any medical staff membership? Has your medical taf membership, medical privileges or medical taf 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 denied medical staff membership, or advancement in medical staf? status, of 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 then a minor traffic offense? iss 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 wamed by any state or other jurisdiction including a federal agency regarding such privileges? Has any professionel liability insurance provider ever restricted, limited, terminated, imposed 2 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 Blue Cross or Blue Shield, Medicere, Medicaid, or any other medical Reimbursement plan; or ‘have you ever been restricted from receiving paymente ffom any Blue Cross or 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/PPONPA or other prepaid health care plan or your contract as a participating provider terminated by any HMO/PPOPA or other prepaid plan? In the past ten (10) years, has any medicel malpractice claim been made against you, ‘whether or not a awsuit was filed in relation tothe claim? any lawsuit, other than a medical malpractice suit, which is incy jo practice medicine, or your professional conduct in the been fed against you or has such a suit been settled, adjudicated or In the past ton (10) Page 2Commonwealth of Massachusetts Board of Registration In Medicine ‘560 Harrison Avenue, Sulte #G-4, Boston, MA 02118 (617) 654-0810 \www.massmedboard.org MALPRACTICE HISTORY FORM Applicant's instructions: Complete this waiver for release of Information and forward a copy to each of your current and past llablty carrior(s) over the past ten (10) yeers. You must account for any gaps In your claims history. If you have additional liablity carriers, you may Photocopy this form, Please retum the Malpractice History form(s) with your original it signature to the Board of Registration in Medicine, . WT jer for Rell tion ‘authorize my professional liability carrier(s) listed below to release to the Commonwealth of Massachusetts, Board of Reglettatton in Medicine, my malpractice history and any and al ims or. for dams : 1. the name(s) of the claimant(s) 2. nature and date of claims) 3. amounts peid, if any, and 4, other disposition or information in its possession, custody or control ‘on my current policy number, andlor any other polcy 1 have had with this or any other carrier 8. dates of policy coverage must be included. Liability Carrier's Instructions: If the applicant has any open or closed cases that have gone to trial, whether or not monies were paid, a cony of the complalnt or summons, disposition or judgment and amount of monies paid on behalf of the applicant must be forwarded directly to the Board. IF THE APPLICANT DOES NOT HAVE ANY CLAIMS HISTORY, PLEASE CONFIRM THAT THERE ARE “NO CLAIMS” ON YOUR LETTERHEAD WITH THE DATES OF COVERAGE AND FORWARD TO THE BOARD. Liability Canier:_CR/CD_ From: _/_{2003T9;/2._ | L008 City: State:_ MA. Policy Number_ CAYM = C= lity Carer: City: ity Carter: a _— From:___/_To:__/, City: : Policy Number. You load additional for Board’Commonwealth of Massachusetts Board of Registration in Madielise(S 71> 10 West Street, 3rd Floor, Boston, MA 02111 (GAT) 777-3086 il S25 In ‘premedicat Education: oes your school have a premedical school education requirement? K- Ow ‘tyes, indicate where the applicant completed premmedical school, .BUSORRISZ Enrolmantand Participation: Our records indicate that (pepsin eppcant’s name: fect, fst, mic, sulfa) ~ Te ee day and yearin the section below): ATTENDANCE DATES: 382 ih p'ti98 S72 ee Sef aa “The appicant attended tal weeks of continuing on-campus education, notless than 32 weaks in each academic year and check one (as wwcarded a degree in MD onteetarioay 2 LL99 {Ed was NOT awarded degree. Please explain season(s) Unusual Clroumstances: The folowing questions apply to unusual ci chcumstances that occurred during any part of of the applicant's medical education. All questions must be aneword, Hou sneer “YES” to anf fs estos helo, sme scien piss so 1, Date myicet sie sy sas of aben® a of breaks from hisfhes medical education? 23 Wes theeppizant over dicepioed or moor wesligation? ‘A. Were any negative roports ever fed by instructors regarding the applicant? i ee'd (262°ON s66r'8 cng cH av Wager 22s p92 419 N03to Massachusetts Physician Renewal Application Physician Name: Alice G Mark, M.D. License No.: 216999 2 u PARTA 5, 1) Current Status: Active Renewal Due Date: 0805/2007 Birth Da q ‘if you want to change your current status, please check one of the following boxes to indicate your new status Cheek only one: (See Renewal Instructions, page 3.) D Active D1 Retiring O inactive 1 Do not wish o renew 5 2) Addresses & Contact Information. Please confirm your addresses and make changes, if necessary. You are required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and CANNOT be a Business addresses CANN‘ Post Office Box. Please ake corrections (print) 1a) MAILING ADPRESS Maing Ade cit: ae 2p coy © the hai 2b) HOME ADDRESS: Home Address: carro sue 2 con shane vows Tepe) 11 Check here ochonge nsaies RECEWED Home address cannot bea Pest Office Box *Qawenospa, Dex eronlktl 22 2807 [Busines Ado ce ne eaartin | 7M: ae Boston, MA 02115 in Medicine Zip: Coury: Business Telephone: Phone: (617)732-6660 Ext. 34579 1D Check here to change shi adress Business address cannot be a Post Office Box ‘Correct your E-mail and Fax Number below: 3) E-mail Address: 4) Fax Number: _(617)983-4196 '5) Specialties (See Renewal Instructions, page 4) Delete? List Additional Speciati Obstetrics and Gynecology a o o ‘6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information. (ee enclosed insiructions and Renewal Instructions, page 4.) List Certifying Board(s) below: ‘Update General Certificates and Subspecialty Certificates below. Please add additional Certifications as required. Board Name ABMS or AQA| Certificate/Subspecialty Delete? Obstetrics & Gynecology ABMS __[ Obstetries and Gynecology a ojojo Page 1 of @a Massachusetts Physician Renewal Application Physician Name: Alice G Mark, M.D. License No: 216999 (Gee Renewal Instructions, page 4) Please make corrections as necessary 7) Drug License Numbers Correctio 8) Other states where you are now licensed ta practice 4) Massachusetts: ee b) Federal (DEA): - 9) States where you were previously ieensed ©) 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 age 18 of the Renewal Instruction booklet. Include any affiliations with Internet-based prescribing services ‘or companies. Please provide all information on all work sites, attaching a separate sheet, if necessary. ie names OF all work sites fu Massachusetts Tocation . (Gee sore and decrpuoronpeee (city or Town) Site | Pacer Brigham & Women's Hospital a Souttyrn “Jamaice. Plain Halts Gri Homoxa Pain mA Q [Woman's Healits Siac chat Hill MAL a o Ti) Gare of patient in Massachusetts Seg Renewal Insraclons page) Average weekly hours involved in: a) inpatient care 30 Inrswk Change to: __ hrs/wk ourpatentcare 20 trsivk Change to: ute 12) Medical Liability Insurance Information (See Renewal Instructions, page $,) ‘Check one, Locum tenens must list policy dates. My medical libility insurance is provided through: Insurance Carrier (complete below) ‘Current insurance Carrer: CRICO Change to Policy dates: From [14 /.6% ofa By 10% Type of Policy: BY Claims made with tail coverage 1] Occurence Policy (Enclose a copy of the certificate of insurance or the face sheet) O Letter of Credit subject to Board approval (Attach a copy.) Cam registering with Active status but 1 am not required to have medical liability insurance because I am: ‘Cheek one; 1] Not involved with direct or indirect patient care in Massachusetts A Goverment Employee under Federal Tort Claims Act (FTCA) C1 Otherwise exempt (Please explain) 13) Do you perform any surgery in your Massachusetts office? (See Renewal Insructions, page 5.) If Yes, please complete Form PCA-O “Office Based Surgery" Form on page 8. Page 2 of 9 onMassachusetts Physician Renewal Application F Physician Name: Alice G Mark, M.D. License Now: 216999 In questions 14-21, the phrase "time period" refers to the following ~ all time from the day you signed your I license Renewal Application to the day you sign this Renewal Application. (See Renewal Instructions, page 5.) ‘You must check either YES oF NO to each question. Provide details on Form R if you answer“YES" to any questions. Referto Renewal Instructions for additional information and definitions. YES NO 14) CLAIMS MADE ) NEW: Have you received notification ofa claim, whether or not a lawsuit was filed on that has any medicel 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 settled or finelly adjudicated? 15) CLAIMS CLOSED Haas any medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during this time period? 16) OTHER CIVIL LAWSUITS Question 16 refers to claims or actions reated to your competency to practice medicine or your professional conduct in the practice of medicine, ‘) New: Have there been any claims, other than medical malpractice claims, filed aguinst you during, this time period? b) Resolved: Have you resolved, setled 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? +) Have any criminal offenses/charges against you been resolved during this time period?” ©) Are there any criminal charges pending against you today? 4) Are any Applications for Issuance of Process pending against you? 18) INVESTIGATIONS AND DISCIPLINARY ACTIONS, 1 oF 8) Have you withdrawn an application to any governmental authority, health care facility, group practice, ‘employer or professional association? ») Have you ever taken a leave of absence from any health care facility, group practice or employer? ©) Have you been the subject of an investigation by any governmental authority, health care facility, group practice, employer or professional association? 4) Have you been the subject ofa disciplinary action taken by any governmental authority, health care facility, group practice, employer or professional association? 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by, or surrendered to any slate or federal agency? 20) Have you withdravm an application for a medical license, allowed a license application to become obsolete ‘or have you been denied a medical license for any reason? 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency or conduct on your coverage, of have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by ‘8 medical liability insurance carrier? 73) CME CERTIFICATION: 8) Have you completed your CME requirements preveding your renewal date? {Yes [] No ») Ifno, are you requesting & CME waiver? OY GNo ‘ACME waiver request form must be submitted at least 30 days prior to your license explration date €) Ifyou are exempt ftom CME requirements, check reason for exemption. See Renewal Instructions, page 8) CME EXEMPTION: (check one) CJ Inactive Status C2 Resideney/Fellowship traning Page 3 of 9Massachusetts Physician Renewal Application « 1a Name: Alice G Mark, M.D. License No _ 216999 8 ‘Glissks One: PHYSICIAN PROFILE ; ‘have reviewed my Physician Profile at http:/profiles.tmassmedboard.org and confirm that the information is accurate. ~ (Please note thet if you changed or corrected your business address, business phone number, practice specialty, board certification andior hospital affiliations on your renewal application, your Physician Profile wil also be updated.) (Ihave reviewed my Physician Profile and anached a copy ofthe Profle with corrections 2 Cl My status is active and Ido not have a Physician Profile. (See Renewal Instruction, page 11.) ‘CERTIFICATIONS 1) certify that I have complied with my obligations to report abuse or neglect of children pursuant to G.L. ¢, 119, sec. SUA, and J understand the punishment for feilure to comply, 2) 1 certify that Ihave complied with my obligations to report abuse or neglect of disabled persons pursuant to G.L. c. 19C, sec. 10, and ‘understand the punishment for failure to comply. 3) I certify that I have complied with my obligations to report abuse, neglect or financial exploitation of elderly persons pursuant to G.L. c.19A, sec, 15, and [understand the panishment for failure to comply. 4) I certify that have complied with my obligations to report the weatment of wounds, bums and other injuries pursuant to G.L.¢. 112, see. 12, 5) I certify that I have complied with my obligations to report the treatment of victims of rape or sexual assault pursuant to G.L. €. 112, see. 124 1/2. 6) Lcertfy that I have complied with my obligations to report a physician to the Board of Medicine, pursuant to G.L. ¢. 112, ec. SF, when I have a reasonable basis to believe that person violated any provisions of G.L. ¢. 112, se. Sor any Board regulation. 7) certify that | have complied with my obligations related to charging and collecting fees ftom Medicare beneficiaries in accordance with the Medicare fee schedule, and I understand my obligations under G.L. c. 112, sec. 2 8) [certify that | have complied with my obligations to file Massachusetts tax returns and to pay Massachusetts taxes, and I understand that, pursuant to G.L. €. 62C, sec. 49A, my license shall not be issued or renewed unless I make these certifications under penalties of perjury 9) ceiy that have complied with my obligations related tothe reporting of employees and conttors pursuant 0 GL. 2 10) | cerity that thave complied wih my abligntions related to the withholding and remitng of child support pursuant GL. «119A. 11) Leemify that I have complied with my obligations to file an Incident Report withthe Board when certain adverse events occur in my. private office, pursuant (0 G,L. c. 112 sec. $ and the Patient Care Assessment Regulations, 243 C.M.R. 3.00 et seg. [ understand that the Patient Care Assessment (PCA) programs at the health care facilities where | practice report certain Major Incidents to the Board. 12) 1 certify that Ihave complied with my obligations to disclose my ownership intrest in any partnership, comporation, firm or thee legal entity to which ! have referred a patient for physical therapy services pursuant to G.L. c. 112, sec. I2AA. Under penalties of perjury, I declare that I have examined this renewal application and all its accompanying instructions, forms and statements, and to the best of my knowledge and belief, the information contained herein is true, correct, and complete. As an applicant for renewal of a license to practice medicine, 1 understand tydt dcriminal record check may be conducted for conviction and pending criminal case ‘information/from the Criminal History Systems Board only and that it will not necessarily disqualify me from licensure. Signature = paz b 20) 07- axe Adopy OF YOUR {AND ALL ATTACHMENTS BEFORE MaILING, YOU MUST RETAIN A COPY OF YOUR APPLICATION FOR YOUR RECORDS, FOR CREDENTIALING AND FOR OTHER FURFOSES, Page 5 of 9Massachusetts Board of Registration in Medicine 560 Harrison Avenue, Suite G-4 Boston, MA 02118 617-654-9810 www.massmedboard.org Dear Colleague: As you may know, the Health Insurance Portability and Accountability Act (HIPAA) mandates the use of the National Practitioner Identifier (NPI, a unique identifier for health care providers. The ‘NPI program is overseen by the Centers for Medicare and Medicaid Services (CMS) under the ‘Department of Health and Human Services. Under the final HIPAA NPI rule, all individual and organization covered providers will be required to obtain a NPI by May 23, 2007. Without this number, you may be ineligible for reimbursement from federally-funded benefits programs. Asa condition for renewal of your license, you must complete the NPI form on the attached page. ‘The Massachusetts Board of Registration in Medicine (Board) is assisting physicians to obtain their NPI numbers. In addition to providing this service for physicians, the Board is the designated repository for electronic storage and dissemination of the NPI number. By having your NPI in this central repository, we hope to reduce the amount of administrative duplication in your office. Please follow the instructions on the NPI form. If you already have a NPI number, you may enter it in the space provided. If you have not yet submitted an application for a NPI number, you may request that the Board apply for the NPI number on your behalf. You must sign and date the NPI form to authorize the Board to provide the NPI to authorized entities. Should you need any assistance in ‘completing the NPI form, please contact the NPI coordinator at (617) 654-9810, would also like to take this opportunity to thank you for your continued service to the citizens of the ‘Commonwealth. Sincerely, AGT Martin C. Crane, M.D. Board Chair Please complete the NPI form on the following page. Page 6 of 9Massachusetts Physician Renewal Application Physician Name: Alice G Mark, M.D. License No 216999 5 ENTIEL 5 ‘The primary purpose of the NPI isto Providers as “healthcare providers in HIPAA standard transactions. ,. The NPI will replace al other identifiers asigned to healthcare provider, suchas those assigned by health plans, goverment programs” and healt care purchasers for purposes of conducting test busines traseetons ‘Under the final HIPAA NPI Rule, all individual and organization covered providers will be required to obtain an NPI by May 23, 2007. {In order for your license o be renewed you must take one of the following actions: Option 1: Supply the Board of Registration in Medicine with your valid NPY. You car apply for an NPI directly by using the NPPES web siteat Option 2: Cantfy you have personally applied for your NPI and you have not received it yet. nee you have received your NPI Number, ‘you must notify the Board, Please complete the NPI form atthe Boards web site at wwwtmassmedboard or, Option 3; Centfy another authorized institution has applied for an NPI on your behalf and you have nt recsived it yet upply instaton’s name). Once you have received your NPI Number, you must notify the Board by completing the NPI form atthe Board's website (ce Option 2). Iption 4: Authorize the Board of Registration in Medicine to apply for an NPI on your behalf. ‘Option 5: If your license status is INACTIVE, you may elect not to obtain an NPI number (Check the appropriate box below, supply appropriate information, and sign the bottom ofthe page. Kwon (PICO WA C1 have personally applied for an NPI. (You muxt provide your NPI number to the Board when receive) 1 thave applied for an NPI using a third party (enter name): (follow insteuctons for Option 3) 11 By checking this option and signing the botom of this page, Thereby authorize the Board to apply fr an NPI on my behalf. 1D Asan inactive physician, 1 do nt wish to obtain en NPI ‘HIPAA TAXONOMY CODES Please provide the HIPAA taxonomy (specialty) codes (refer to Renewal Instructions, page 21 for more information). In addition to providing the taxonomy code, please indicate your specialty in the space provided (Taxonomy Description). The primary provider ‘taxonomy code is required if you authorize BORIM to apply for an NPI on your behalf, ‘Taxonomy (Soecialy) Code rnoroieTen FITMENT __aale Provider Taxonomy: Oc) O00 744 Provider Taxonomy: OOOO CO ‘NELREQUIRED INFORMATION Tan ongoing effort to improve the quality ofthe information we collect, please review the following information and make corrections ‘as necessary. Please note: This information is required if you authorize BORIM to apply for an NPI on your behalf. Social Security Number: Ae Country of Binh (if outside the US): Bl Female for Falify th 4 18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly and wilfully flsifes, conceals or covers up by any trick, scheme or device a material fact, o makes any false, fictitious or fraodulent statements or representations, or makes aay false writing or document knowing te same to contain any false, fittous or fraudulent statement or entry. Individual offenders are subject to fines of upto $250,000 and imprisonment for up to five yeas. Offenders that are organizations are subject to fine of upto $500,000. 18 U.S.C. 38714) also authorizes fines of upto twice the gross gain derived by the offender if ti greater than the amount specifically authorized by the sentencing statute. seat p i ‘Check one box: 1 authorize C1 do not authorize the Board of Registration in M authorized hospital, heglth plan, or health organization. formation on this form is true and accurate, Dae: _@ / (2-/0} 1¢ to provide my NPI number to any lease sign and dateo conf}rm that all of the Signature: Page 7 of9