Texas Medical Board ‘Mailing Address: PO Box 2029, Austin, Texas 78768-2029 Phone: (S12) 305-7030 NOTIFICATION OF DEPARTURE/CLOSURE OF PRACTICE In accordance with Texas Medical Board (TMB) Board Rule 265.5 when a physician retires, terminates employment, or otherwise leaves @ medial practice, he or she fs responsible for: {i} ensuring thot patients receive reasonable nication and are given the opportunity to obtain copies oftheir records or arrange forthe transer of thei medical records to another physician; and 2) soutying the Board when they are terminating practice, retiring, or relocating, and therefore no longer avaiable to patients, specifying who has cutodlanship of the records, and how the medical records may be obtained Employers of the departing physician as described in §165.1(b)(6) of this chapter are not required to provide notification, howerer the departing physician remains responsible, for providing notification consistent with this section. Please print or type your information: License information: Physician ‘Robes S.Abvev, HD = K59S3 "ne icense numt Name and address of | egy acd Vasco for Specialists 0 South Teys' practice you are Ye Coll leaving/closing: uate n- ail anes | Me Mtlen ) TK +3504 ‘Type of Practice: 7 OSplo ‘Hospital based 7 | artnership/group ‘Clinic — Hospital affiliated | Other Reason for transfer of Retiring Ci Practice closing records: Relocating Cl Other (please provide explanation) | Check the box describing @otice on website or in the newspaper the documents you are ten notice in the Physician's offic providing: ‘etlers or emails to patients seen in the last lwo years Physician's email contact. | pobvev S543 @ AOL. com | | information: | _ _ eee || Vennisence cane logy / ‘medical records: will be the custodian of the | Qoclors, Hospi fa) at Renai 2oar ce) 7}. | Contact information for | Mailing address. ‘Phone number custodian of records: 43io N. Mecot! Rol (ase) 262-3442 | eallen, TH #2504 (G56) 362° 23/0 | corty that statements Ihave made herein are tue to te best of my knowledge. pate change vecomestecive: Ut /) 22.022 Signature (Required): 08 ate Page 1 10/20/2022Texas Medical Board “Mailing Address: PO Box 2029, Austin, Texas 78768-2029 Phone: (512) 305-7030 NOTIFICATION OF DEPARTURE/CLOSURE OF PRACTICE ADDRESS UPDATE Please keep this Board informed of any changes in your addresses. This will ensure receipt of your renewal notices and permits, as well as other Board correspondence. Please print or type your new information: License Number: KSt53 ‘so Robern D. Abrev , WS | MAILING ADDRESS: PRACTICE ADDRESSICONTACT ADDRESS | FOR PUBLIC PROFILE: ‘Srwot or POBox Set | Sule orRoomNeSS*~*«S Rl Gig, State, Zip Date change becomes effective: Ge (2022. Signature (Required): on Signature Return these completed forms by mail, email OR fax. Please do not submit multiple copies. The submission of multiple copies may increase processing time. Mail to: Texas Medical Board P.O. Box 2029 ‘Austin, Texas 78768-2029 Registrations @1mbstate.t.us Fax to: 888-512-2581 Page2 10/20/2022