You are on page 1of 46

,._:.

.,.

~I

.. _,."_ ......... _ --'

Board of Registratlo'n'in Medicine
a.ton ............
An AllnDV .........

Commonwe.lth

of MalMOhueetts

.~~~ .
.

10WMtllrMt 02111

...... .... -.... i
""Ien

~

. .. ,7)727 .... hi: (l17l4l' .... om. at eo.- AfIIIN._ ............

_...

........... ..~--r
. .....

-:.~ ........ a

............... _.WI
_.,
--

.,.,...__
11

...
(0

..

April 24, 1997

--••

_n&1I.D.

BoriI L 0rIdD, M.D,

Rc:
])oat

CompJafat No. 97-053

Dt, 0tJda:
TIle CompIabCaaw .... of_Bod the .. dctJrm _ ed. Tbo Bo.-d ~ bawlwr, wiIbe4 til oftW you ICIvIoe ID

to tbo padent'. ~ofialeolldYll) OIl perGMltba. 1bemidlt of. trMnIttc ................. pIiyIIoiIn miaht IIIIb to be ~ to tbepetleat*. ....... will JfkeIJ au .laaaway ill m

........._been".e'" NPftl
NIl

JOUS." While. "'_'. .,eerta
_-.

I

.

experteaoe, lICIt. ocmrtq
to_,

That you foryourooopcotioa iD the'~ of1bil CcJmm............. 1be lime ID4 etlbIt widell,.. .... ed JOUl' ....... Ifyuu law l1li)' qI1IItiaDt, .... aIIt_ at <'17) 727.1711, BxI. 3751'
or write
to me _the

n.

abcM Id...

9J--1<
DeircIro K. Caaaumer Protecdoo 0ft'Icet

StDcere1y.

.

\

u.smms

,

.
...
I

_---01' .. .., ...

._- - - - .. _.

0.
..

............. 11 h"1JIlIt

'1"

01146
m.QOlO

.......

1117

IDIRI

ca..m.

ar.__.

1n ......
COCdIID

DoaIIIII:I7.oA

In ......

..,
... ~Il HIIIItIg

.......
... Q

.. __ 'If chM. .... fDr

..,.. _ lNI_ _on
~ HIr~ pIIGIdIa

___ ,lit.

......... CIII_ a ... .., " _.pllllntfDr_ ......
lMMyofpelvlcandvlQlnll..,.. '1.11
is fdlyllllt

to

wt&

_ror _,
_.....

n

L ShI_

........... cIIt ... VI •• __

Widng .....

-tI1ItvZellallDfIIIf

_.,....

...

••

toctlql

tIIaI

.-.

__

GIdIrtD .......

...,. .._daIII..,_,
pllllrta.

__

..,aw ... .....-1' ••-..c~_.It_,.. _taar.u._ _f8QIII.
......,...
UI

...
_ '"

mdDIIlJ . 7 .. lhImd:IIl
tD ..

_11

,

.....................
.........

_

'1 .........._p..111........ __ .,_ar _
... ~OIIG1'W11111d.
It....... ....
1'IIeN1I

n.._ ..eal"""
.-qOIIh
1IIId

_

13

_

_
., ,.,. __

_

=. IIr...........
'I I~fn."

.

PaIInII_

.

"

IacII __ '7 '

.

..

A ..

.

...,111 111

_ar

_~

_

u
_

1,.1111 __

IL22 ...
..

..1111 6."•• '• ...

_ Clltaf ..

_..,
1ICIft;

....

.. acaammadIII_
MIdIaII ....
I...,

OnttA

...,

IIIac111d

_

tan .. ......, __
ptIaI

_

raana •
cn.QI
IIIIIDn.

..,
'"

,._

",

-

...

ant

1111 CIIII\1IlIIaIrdala

bIforIlIIf

illClDarIl .....
1I ....

1MI ...

·IfIIIPIIhIIICID"
the

bll1MIIId.we CIII

•CXI"''''

eon lIw.llpIor

...,..., In OIdarto~..,
.

.. 1hII1tII mil. Gin till Q._IItIII~

.

1Idon,......., ....
.....

.....,

1IMMd.
.. _

(0

i
...

...

.

' ...........

-..u. ~

~·DedICI,Ne dIe ..... oI........ 1'IIiI c:.-.t_

.u.u. lftlP"·Mi__:_. .. . OptI orPlq _c.et at(Q~orltoc..Jwldpa.B .. tl.fM'A 1aZo)

,.. -(bI1& IMI) of"",

.........

_ofCha

ar

.....

urAcup..cmriIt (__

per 1_) ftdac.p.

_ ......

6£;€:lS (£}q tJ
Zip Code

09-1;5

(; (I . "7 t '2 Mae ud IAcIIioD ofHeal1b. c.e PICIIity (lfbowa)

rJ
....... Medb1c.. Plain"'" MlIcondact
SauII ......... · .' laqrall ad by AWol ..

............ ..,.._
DrIll
.... lDl'IavIdtM...,..

c

(]

[]
D
.....

C

CIfaaIIuI~

DnIa DIdII

.... ....,,....

u.a eM DIP'

C

o o

by~.BIaadadII

[]

Owt-..ar~
Ocher

C

RacordI.

CI

Iftud

F.... ~

,......

BIIIInI.,,8IMDeI Nat .......

_ ....
; ' •.

aM

IJ

AM ••

••

II

1s:=::=~ftM=~TMBNf=~AlDUlUI.BASIAMY ANDALLOPMY.~~1O"
I "'TlBAUl'IIOIIZBMYMllirAL HEAL~1O..c:I.BYAUM11OMI,
WAIVEIlal ..... PS'YaIOTIIDAPIB-PA11IIMTJllUVlUlCJB.AI.-..D ..... fJlJI'MIIat 'DIIt: )

1lB018DA1'ION 1N'dDIaNB. "AU'lllWll.1IOM

JMG.L. 0. m.t

....

..

11 iliA _

(Or ...........

......... __ ............................ '1'
~

~1't1AL

tbA~·,~.

-

......

--._

_.

4 ...

_-.-_--

and I haw boea.. shoved betWDeD lcp.~...J1IIIIIt cIrap be pnMded...." M they looked at my medical records.....1~. 0CbK pta tor ID eddItiaaIl hoar.. 8) PJiIced In adnupa...! . made to \ail ... Broke 1ato . 11) Wont pUn ever experienced.. aad awatiag.III •• III .-nt. pused out.....into pmcecIure room.. 5 'days hdD 111m.. W 1'* beIwe puceduae tbIt 110 8De11baiaor paiD mr.. IllllitIIY . aIiIt.. I ADDENDUM TO COMPLAINT I'ODI j • far paiD . Z) Allaqic1D"" tbrms of 8IIIIIn1 . OWl . II 3) I .. to . 6) 1) told ...uriDD umpIe..... 4) 5) ._ iD CIIe... i......... . ~. . Sed801 \WIUId be u. - ~. J3) JlrMJ of blood and presumably fetus \VII pIIIded in fiuat of me u tboy left the 14) Had 110 uriDIre ad 0rttiJl follows me ia .. room. IidocaiDe hid mt been siwn time to act. widell __ .'t . CIb-waIk compand to my Iuqerics in the pill..... I 'WU 1DId dill IhiI would be •.d at Cri..rm.. chap Indoorway in my t\d1 view. .. I ...red me [would be Ifwa WII_""" alldlliw 10Cd. _1IIll am to miDe...... ScremHna 10 Itop . I) R*ndbyMGHto~~"""M:ytemi MOB ~ MGd -.. wmited. _... .. u..... lidqcalae ... p.pocedure.. \GDid.. II) myone~' . still hadn't . 16) I coadDuc m haft aigbtmaaa to this day. 'fIe .... tIuouab JOllIe extnme IUIIicaI procecIUNI and never· comp1ained.. Wabd in WIidoa room fiaD 7:45 AM uatil 11 AM.vioIaticn IS) 0ddD 1bea. liml&lntDUlly..... _... 50 exbemo pain.... It II DDt . Ix the pain... of. then sit in_room widlS.. Apia. AboldaD 10 be perfonaed 116 waeII:I. Told to bdaa aecordI ... I feel l'IIJM'Cl Do DOt Jet 1hII .. 12) Carried ott .. but the opendoo would be only "sU8btly 1IDCOIIlfoztIbI1imiIar to ClWIIpI. When Mbd. ... in. Too WIIk 10 pro_ tldlfiIrda" humJliItioD met . .. Made to UIIdnta.. speculum Ibm J01IIhly 9) Lidoc8iao iDjecIad ad diJIlan iboved mao cemx.... ... 10) AspirIIaor muablY tboved in and out UDtiI·__ IiDIaa ... while 0ddIi 1ac..... . Curette IClllPlna • well. wd. .. ...

~ THf8 APPLICATION OEflTIfIlD RETUflNED WITH A 8UI0 PAYMENT.. A NO 51701 100.".. COIIPLnE AND.lo c. I12C.) ROr." PURSUANT TO M. ¥II LATE FEE NOTEI A.00 01 15 (".MASSACHUSETTSO~ RENEWAL APPLICATION 1986-1988 IMPORTANT .·OMlD Of REGISTRATION IN MEDICINE R60M 1507 ·-100 CAMBRIDGE STREET BOSTON.IEF. MUST BE SIGNED AND CHECk OR ~y 0fIDIA 18 D LICENSE NUMBER 'f .. c.. HAVE FIL~D ALL STATE TAX RETURNS AND PAID All STATE TAXES REQUIRED UNDER LAW. .you ARE FEQUIRED TO COMPL£TE k (JI_ (seE TltE ~ ON THE AEVEf18E 51~OF THIS APPLICATION.' AMOUNT FEE U"n:TU8I"IFNt-IIoFO 1M) .GJI!I1I1ATIOH"I. I CERTIFY UNDER THE PENAL liES OF PERJI.CHUSEns I'Uc'IBE PRINT ANY NANE! 011 ADDRE8fI BORIS I OIU(IN "r\II -". P. THe ENCLOSED INSTRUCTIONS FOR DETAILS.· .HAHn:""" 86 AOCWTABLE.. YOU MUSTCiHECK PLEASE USE THE ENCLOSED RETURN ~OPE . MASSACHU8ETI8 0I!2t7 3500600517011 011586 10000000004 t .. cOne REDACTED cnov . O~ST KNOWLEDGE AND atoI...00 100. PREFERRED. HC).O. BOX 8 • 00 NOT WRITE fti:LOW ltilfl LIME BOSTON.. REt! I IF YOU ANSWEfIED "YES" TO ANY Of THESE QUESTHIS BOt: OIi'IIONAl TIONS.ffrt THAT I TOM\. PERSONAL CHECKS ARE PAYABLE TO: COMMONWEALTH OF~....READ. I 49A. PAY THIS III. lIE.G...

--....0=-.r..~.. E.. ptlCtltlon. (ChIck one) I HEREBY CERTIFY \JNOER THt: PfNAl TV OF PER"IJRY THAT THE: ABOVE INFORMATION lOt" ..aclMlon (Inl8mltlonal... 1l1li In .:...... IS TAUf. mv C..:. nlqunmentl ~ 1/151114 a.. or iij..s."" III. Have YOUbRn IlIIIfInd«It In In~ criminal proceeding athlll' thin minor traffic offenMI camlilenCld 1I_1011111? . ...~~....O... .:.I... nltlonal..n. ItIt8 Dr local)? 1 n....c::i=~:::-:-~=------- IIQN THE JIIIONT Of TNI' CARD) .c/'... YEi 1 ..::(.. . Slatel otn.... TI15I8B • follows: _-'1:.1:. ..__C~~A.. -----... iKiIP&I or hNlll CIfW pro!:!I!k!n!l IIIIdlcal . cYOU"" AL80 ~.- I.. by IrtY govarnmentallutlloflty. IIuI¥e completed U. --.lnactlw _. Hti5 ~ dt¢pIlnary ICtiDn bien tIlIlIII_nat you In IIMIIut tin yam...:......_-. -81Q-N·-A-:ruAE..O=--...A. than MulKhUlette In whiCh you are Itcenltld to pl'lCtlca: fiiijilt.~_..

..d~'. . twhloh""n..aY ~~1HS II._.1Iy .. - - ~tJs.... . f'OfIIM (PN)NT ATTMlta IHaT8 ill TRUE.:..6:Y .). ~QG..al6t.a. 1 ..) rv OF fII!A. .....IUIIW II.. MASSACHUSETTS 02111 RENEWAL APPLICATION MD. ConcMt i••.. iiIiW .. 1 . IIAI~ "WIIT~... one or 1lI0I'III1II'16' IIOIIdi? NqYnmtn ...1 _ 11.Ylr. I WILL NOTCHAAOI! TO OR OOLLICTflRClMA .va~MDRE~ THE MI!DICNE AIAIQN. 0 COheoJc If yaI... CIJn'IIY lJrIDI!fII THI ...... t20yelll'l. u e.. .1 OERnFY UNDIA THE PlNALTl!8 OF IIWUR't NOTI= THII .. ..&..i. OAlIi'O __ tID ...D..PrlnlNIIH: ~ 1DfCLOI.J. 1IlIIMH. ffa..\CENIE~ mI_ PAVTHI8 AMOUNT Fee - ""- LATEI"EI 1 51701 ...I $100 100 06 12 87 BOllS I OA·rt.....I2E. ••" .. ACT8 OF 1M1.. IDWITH 114. ..... THAT ALL . UltIllIl_pIIIl ...lll1II1 .:. ~ • ~==-~~~~14 II!St..". It t 1m In IfIItve 1. ......". ..t4. . TO llaL 4M.D6E st.. M1\JIINI MID. IWIlIcIIIyoUh .1Iy . . ~_~. .~·..!!!!lI' Diii&I &:...ot One.... ~~~ --------~--~------------------------------~------~~--------------." • 1n the_ ~endlnton till .( fir' 4 II •• ellMdtopqctlce: a "9~lpce cAl): TeA'" '-- f1est _ II I k ... . L M1cb18chaot'DJ-4. ~= : .... _oIher1hln~ Inwftlc:hyou...O..... ...1) ¥ AM) IMQO INCl . ~c.lIO. fORM O&t'=tlJ TO....afOrldultJon: (~0ne. AmMcIn 8peoiIIty Board cartllIIId'I 4....~TION ON TH.? _ III D. _ I "_ ..0 pI'IOIItior"" (et... ec... II QUIITIOn1 ~ .-EBAAl"N'tj MId~ SdIooJ J~: _ :C.BOARD OF RlOIITRATION IN IIlDlelNE TEN WEST STREET BOSTON. L... OR ADIIRIII ~aaow YOU"'" IIUO~ 1..L.M. c. 1 • ~ I. ou.dIdI..SIt oJ i.1 IAJ&LTHAet __ - 11..rd~lnlhep 11." 8._______ .1It11 PLIAII!!""'" Nlf rw.i1.c. I &ra" 7~" Cek"~..AID AIL stATE TAlCU FI!QUIN!D UNDM LAW.....) us S & u<'s l M...lly~prM Sf..c1 0211[' I Ha"· 9£ I._.c..? 0 '.JIjI 't.STtJ..2..."'PLDOII .. _..... - 1887-1_ 'r ..1. --------_...:e is ..

... ... __ -. 11• .. 1OInS of Ten WtIt 8INII. "....::t=: ....... .._ ~r u~. III.d CIrIIIId7 (Y/NI tI)' IS. -.. ... ~~:. 3Id Aoor. 10.. D...=t. "" 1 0Ib 30 11MIttI o.l£" I.~ ...-_....O.... --" " ....... Ddtcl"'lMO/DIV'M:_ 8.W..LJU~/ ~_..... .Il~K......:=--.......' ""' . ~ IJ: a&l: fIIIIoIntof ...~~-------------------------lie.. Bolton.. 9uIgery PMA phI.. __ Ntmt:...IIIIdIt:.... fCI'*o_ ... --~~: 11..alng --" --" --" _" __ _" ..".. PI\f8Ialin . EdIntIon.... .... ... .... "... a.... Q~u...) EM of. 10.... --" __ ao PIwoIIOe! 'bfoMrIG a-I rrmr... 0......nt Carw .. 8pIOIIIIy a. 10 PIIfIt/COmmIRII ............ _ _ _ __" ..: t. ....tItIf ..."CDdI: ".- _ _ tMIIInOI:_ 3. aoM1llnllll ........ IML_ I..._.........v'.. ..-..... (W' NM 00 or PA 08 .....to¥"I'o 0DdI: _ ~ =-....OIIWCIw ~d.D...(I) 2.._~~.mClt._) 1... Bod.... ~'RiN ...... ......~:--- FdlyCDdr... PI ItI......... IIMCYM . ""'1):11~ 'D.. 1B~.... ~ ........... .. 1 of I ....WafIr...._. ".... vi.". "' ..". .. ioaIIIV PIwIIIDe .: : .....0IhIr " ~d"..... .=~. I Orkin ".. I/HL_" MIIw1IIII __ " __ It ...AST:............._ . toaIIIIlllGulllrNo..d '" "'-' _""" ...... d) TiIIpIIorII"""': ~EU!J.net ". • ..........~of ....LE_ IaIIDGICcIodIt".. BIIIIId 01CDIIItII . N8 lilii'ii of .. •...b)0IIIIr. 111111 AptaIDIII ....bl AdcIIaNII __ ~~w$~P2~D~Aw)~I~/~A1~'-WY'~~s~~&~~T... (I........--=~-==r. '-1lIIY CacM: Q~....--------------------------------------------------------------- . c..:... DI.:z 0IIw. FP ~ 111*4..... ~ 1IIIatIOn . 'I. ..._.fNT!1 .. .. IoIId of....~~~~M~IV_.- 'Bo RJ S ... rra "rnh .. ""'1QIIIIlMIO: ( ~..1....--..ICI'*_ .......1) ~ •• IIP/ ..T... ~E...': " 'I..JJ....01.........:_" __ __ __ • aa.......c:. .....R...... 1 ... ___ ~ . " rMdIcIn.. "-Illy CcIdr..L1......:r=-~=-=..... _ --" 10 ... lI4Lotft" ..... s s .... " TtrM:...au • . "ZiJ ....... -_....=t.... 1~ 1laltd00Al ......... III CIInIo 40 HMO FfIIDIIIr /JlJl. .r= ...... ....~ Ban of OptiWiIIrrtaIcIW INId III0thDpId0 IuIgery IDMI 01 0I0IaIrwng0IDty 80Ird 01 PIIIIaIagy lDIniof""" a. _ "blV-~ "d)CounIIy: 7l.~ N._. w.... _.. M...l. -6........ _--IO"".... ...-UAl~TL------------------__ ------~---_wIIiaII VIllI ~ pfIIIIIIQM.l"'* 1): l..........._ 7. _ fldlllyODclt: _""'In . ~ /I... .JRR_" 8peaiIIty CoI:II: --" "_'of TImI:_" tAIrIoII~: PI PM PH " 8 CAS o 8alrd0l ..~................. Ill ..(M..ca.. ~ ~ CacM: willi wIIIaII.:l-. z.£ 6. __~ iM-_ \ . 1l1li U T8 _ .... ~wMlwhIOII. • ". 4OMIdIoIIII'roMlGhirlg • 0IMt III MIcIOII RIMMIh .....n .: ....... Ul .._ ... c-de_ "0) __ : CocM.•..nm..) T~ 4.........EL FEW.._aalIIIIII! ."" ...Imf).. PE 8DMIof NUaIur MldlaInI l_rcIlrIOblllMoe...=..1) lO.. wIIIah.IIlID.. c.. .""J a~S '-Illy CDdr. e..!!2 ...

. __ 14....) dIM.__ ..."......l ~ . IIIIn .~~~~... .~ .... " 01' wppIIoI6:In •• oornIIId~.'1of I· :....._ . --...... _ ""_" _ ... .. a. In .... . thin ..u.~~~!.: Ml l: __ ACTNE~ tu........ ...... () _GfIOt· ........ ..MIIII. _......-.:.. 0Tte\WI8!1DCIMfI11I)_. .Jl. or"_...)!SIIf. . .... "_""._""..." _... _ .. Lh 'IIAr 9'''< [cc. 1oIt~ IpaallllJIaard OIrt111oI11:1a11? Jllllllalndllltlcf_ . 11.......... .a~ ••: .WACt'M!_ 1 .... _"_"". 1I!IJIIIIr?..iiiiiiiiii•• iii'ilii... 20. ..._._ _ " ... lI'DU 18._·_ ..tI!dnOCIIIIM"_' ~muIt. vaur abIIIytD upon filii' 1IbII1y"~ orlDfunaIIan ortoMIaIIIM _ UlIlltIll.AN)'l1li_... .."_ In . 1 .........._...._""" : _......: .... 1... IIIMaampll!ldrlriC......~4I). ** o-r._ ofllllClllMt ....._1pIGIIHy1laell:ll? ...." • br~'"....._ "'fOIOwIIICIllIIIII: 01( I< I AI .. ~~ -... l. "~ ..1IIInGr1ldlo...._".bl 1IyINSURANCECMIIER_ LliTTEROFCAEDIT....H'lUnypMClng ....): 7....~~"~=~~~~.... ... 13.iil6'l1i.... "''''''I¥--or CII' " .~. 11m IIPfIIWIII til bllIQIIIIrId'" OIIIgIIrrt __ ...WS«HO . __ - 'YEI"" ...2'11 It " ._..~I:_In. ~_IIaInIId". II1II1_ MI __ I:IIIn:r.. ..." __ "*" 17..".................... PlllWltaf UUl 17 TfnIItInI I ""~n ...... · IIOMI or .£flRL .tII. 1IIiIIIft)? ... 1cIne 1.. we.". CwhIIIMror nol _1IId In IIIfIIIIIIIII".. .. ...ii:iiii. OIIJIIIO"_'" 11M~ ..CIIII:''''''''''Fann.. ... .*rotCld: II tit 0 A..fOIIDwI: ~1'IOgram1n: "/tI_" If'.. HM)'IIIIIIad .... .. __ ~ "...crMTENTCME_ MI. 1II0nl.... _.. _ .S...cIIno . _ ..=~....__ ...at " .. .. **"•••" .IpI_liiii·ii..e..7 ". _...~_ .. _ .."t.. . CII' .I.j'MN. i..a/r... _ medIaeI fA . ~ "" ~ J"""'~'14... """"10\....._... • J"SlLV I. 1lIIIIII 11M! tIQIInII...J ......~ 0IIIr lL 11) .. M....." ...1MlDn't.......... ./tI_lIIlI""'" 12..*'IIIIIL lIlY"" JUI'IIIIIIIIIII1rIiIIdIg 1l _II cIIIWd __ tDr 1IItII ptMIIoIl'I*IICIM dnIgI? " . HM)'IIIIIIad_IIIriII . If a..._ iU ....." (notNA!...~~Ir'tlt/ ....---~ __ . t#Ii.... 14. __ ..) 3' AIJIj ••• " ...dIIMdIIIt "' ..... III."1ftIDUJIIftJf.......... ""..... 1IaIftIIcj".. .........1 .".. you.... _ 1nIIIIuIIon ...... ' ... ullae . NDTHJCLWON DIIECI'.. ~... CMoIr...... ...M" ••~" . .....lJliL.....fIIr ........_ - I~ "'''.. ACTJIIE .... IIIhIaII_ 21.. " .......HM)'IIIII t-.. ...

._'-' __ C......._...._ 00dIR iJ S 30 Vw~2 ..-.. --- o Obstetrics and Gyneco~ 09 l. na my..1.."~ --If ~ OtiG Hptg-".. ..110 .*'..... •• Drug LiIIInIe NYnIIII(') (If ._~ Mama o..... ~ w.... b) AdIheI( .... ".. .~1ooIdIt hAwmltlalttam8Nn:l .. n..... Ivan-Fran~ov$kij 00dI(........a.... ..... _ .......... CItyII' . . b) . I 7 "". i . ." 30()0 __ CIIWOt..... cto.. . ....ar-:MO ~ prw4IDe(Aaa): CGuntIy 00dIt· .:.."... . .• "....._ . _" .. . DIIId 0/14/63 Sex:M SIN I: a...". In MIll. ~ (If._ .. ....._ ...afM: LJc..af .... Dr.. I.... U..." 111M....JIadmr (You .""... b)_ . ' [opIIgnIIJ: I) ~ l"'OCIdIpI.....~....~ 1~ c:w..._ ..... ...... _J__J_.........R. :... \RI~UN bUILOING.... c..... .....DIA-... """*'cM'IJ..__J___J_J .....t... ("'Q1) ~ i "'1inMt HomI: 8ahDaI cadi' _ . AIMricIn CocM: Codt: 8peciIIy IbrIt CIrIkI? (V1N}oI CadI' (DEA'L....... ... fII• .. I""__ 0S31 1!!!fl ". y_ ChIiIIIIItI' ~ 17 Lf'!JrA... .) 0)"" (MA) fM'_ _ . (IMVt): ~__j__J_ I "(INF): ~. ..... ~ :- ..b) If YES EnlIr CodIt: I os... ... rou .)17Q1 1...... '*'...... .. • . ...1171 M [f'«0fIaaU._.. " Co&ItMr Code' Uo......IllqUbmenIlin DflIIOtIUllmlt~ Fann.. M.. ....r_ ~. AdfhIt· Cil¥lTown' (1.... ....~ ..... .............. 1ft..." .. _... 06L12... HA 01904- --: '-6eaO o.. ~ ...... Meoical Institute J If_.... MIdIOIt'" : New" . -----IIIJIIW: CedI' Gall ~~~~ 7....."iInWIId..... dill: by" 80ft ~ ......__ ... a.".......... 1IoacwId: ..... ..I'Id ~rn.. 4TH fL..: YNN.-i"GIlIIfHIII.: . ........· 493 WiSTcR~ AVENUE .CotIntJ)...0116 o._. . lhIwalVerlllUlt be oIyourO Ile-..............) ts~ lIGWliDItII8d ...191 ..".. O . ._ .............. I .. .....1 IV. •Q ' ... ... .... lfIIIIIIngtD .... 7 pv__ . . '~'''''wtiah .. rtfIIdI... • .... ..E..... AddNI..w..... •••• • . : ...... aORlS 1 ORKIN .M..... 1.. 1OIIf......... """): . 1oIIawIng1lilllw. ..

... 1OU .. .. ~ fltblendenlad -...__ ~ .ou had. or... _ "......... 14.. _' 1 Iar... whIah ~)'0111'' ' ... ILCU............. (QMI..._..... mInar IIIfIo aIIIIIItf a h_ _ _ _ .E'1'TIRClFCfIiDfT_ If "'...t HM _ ••••I JI"'1t .~~I~·-------------------------------------------------------------a........ Ift LIlt ~...._ _ _ - _. . OIIetII .I. In""""'_' II) ... ..!!....sill II ....... . t.J......"..._ .. .. WiOII )'OU~irMlMdln_ ~ curentIr InvaIwd In .. ... ~ . 2O.. _.............." ..._ (11_.91 --~:~~~~VJ~··~}m~. __ II~prinoIpII wcn ... ...e.D~... lila . ACTlYE... ••.nr. .......'.I" M _ _.....e.. .. FdIy~:___ (MA)dIIIlnIWdton boDNIt) you ." ndInI·.... f.. /-. OIhIrHllll\ FdlrCc*:_15:...._ . of ... .G. 11... "_In. f1t.".. .. ~<*IaII""_• ... It.... ..... II1IIFonI .....___ IIIIIIDtf-_...... 12.-)IOU.....tI) tv .. ." .... ... "...... ...".... ... .orpl'llCllaeOOlIllUled arbltn bf fit art fOr..../. ..1....IM".....orNO __ ..... . ......... '_"'" ...... (... QlNfl...m . .....N•• IBU . .. ..-_..dIInId.... PaltOlwllllt n...~ f... InIDnulon . ".. ...... II.... ' QIdI. 10..IAAHC& lUll __ .... c:ur.--..' ••••• .. 6.. .......A""nt __ ". ..."JCIU belnodld "" ~ ....GJ.... I_. __ ..... ..... Q...._ .. lI.__ 11-' br (a) IN8I...cuCMI'IIftIWfn bInlnt .. . .... 'II1II ~I ......--~-----~ . ..a•• _' 1M..._ _ I.. f7. I .n .~. nac ....~1n1M.... __ CIt) t.... . .' t' t' ••••• __ ••• _ iI ••• _ •••••• 0IhIr MtIIth .._ .L."'1" • ...nA..:.....~--------~----------------------------------1r---------AII. •~ b) In.......i ------_ --_ ......... ----.... raur ...11" I .. but •• PAl1ENTOARE..... FIaItr CadI: ~_2./~AP) ... Haw.. ._ ............Jt....._........ "''''In''' FdlyC0d8~':""_ -.._((JMttk_ ~ \ __ 11.._? medalntorlO~ meclCllntor _.. rou -.. wen "'na? (SIre r..._....._ ....IIO . ......._ .. oflll./. hoIpIIIIOIoIhIr t.""""""" _....H.. ..... IJpIom . _ ..' ....AP) FdWCa*:_l'i.. ~ .. ••N CAPllEr:uL_.utll .... . your. _ _ ......... .......InIng1n I) 0) .....DIdt: _ ......_~ "'1pIg""h ' _.. .. ...... 1:1) C... '11111"..••••~+. ~ .. r... t'...I ~. If.. /0 .....CD: t..........__ .............. -. _ .. pIrIdInf Gr""" artnInIf~ penlingorhalany. ... till... I( '... 1It 11.........._... In .m..t~ ....1N'J CodI: Fdtt Oodt: ~ ".. (I)~ ~ (f) NOT ~VEDIN DI~JlND1AECT ~ EXIiIII'T"_ ~ . h MA... J '..... .~.... III\. QAItfdaoIL_ lnthl.........JAII1 .... ..IU juriIdGIIDn dInIId.... .. .... ....."mtnIII 21............"..dt-*. _ ...~prtvIIgn .. _..'111......._ . ~ ~O~R~~~'N~ J FILL IN NAMS ANDNUMBBR: ~UM*-_. CIa fnICruoGGn 1IuoIM) Haw..... aa••lall...JIJ') (M'J..._ _... .

....amH4Wi·' ...... w. • ._.. a.. .. .t....... .Cc!&tI9) (See Tillie 1) S5 08$ .........hr'I-Lt J)apleCNQlXl).._... iIIbImldoomwm ._ C4Wiidly A1IMdcID........J'l1i1l . am. b) a.d 01Il10........ AM.ESTERN AVENUe ~RIS~N BUIL3IHG. __ lID ~""'afpdal'cwrtficwqr (See 1'63) Oadcr:: Code • Dras. '"&' B=n= (617)592-3000 .... "' __ afacd6eddJeat. .mnweaItII ofMll......u.. ....... Code Code 1f000PIII: ... 10/14/53SS1 k M DtdDolB1ld&(IM¥Yl..... Call.. bythB ~ " -... S-OM) 9 l)ar.~ """"_NraIa: IbDD ( ).~~~~~~l~)----------------.....IITE~A ft~ o... 3rd Floor... __ ....... . MadIaaJ..O-~Bd: Uc __ 11(111 i... •• --cs)...w. D....... ~l9J5"""" Re~-..... ~ If.. y__ IIDc... lIIDCiIIOd. ~Naaher .-... ............aa..) PaJcnl (DBA) o bO ODs~etr'cs and Gynecology ----Cee -... I ..adluletlB Baud ......te.·i'd~ ~ QI..~ ~I.. ......11' 111:- 1w1\ ..._ wm teetx .----.. $25IUIO-. SpecuIIr Badc. __ n. fnIIIlBo. . lalte __ M'_ t. 1U•• 111 jilt.... Uc.....-0.. NImD... 5~ b) 0tbK ..."AlplCIIIIa .y/IbwII: A7~ IHI £Ill' ""It CcJaaay eo. ....... 4Th FL.pnII'iaaIIJ .... If C9' ... far _I t odIIIIr.. A--=... . ...--wllida.dfied. SdmaL 4. .... .... ' . Pnt ..... .... _ol Ivan-Frankovskij ~ed1cal Institute YccOa...... Ten West Street..-" JicIaIocl1D pnadoc: (Ahbt)..-. 2Iy --..... Coda: (See Table 3) Code: CGcID" b) If"..1 .......... _W_m¥e 7....... 'IboW8lWll'lDIIIlhe ol)UUrCMBI ia.......eg........ ..or--): Cdf/IbIIII. NambII(I).. . .:.. nl ..: c:awa->o 493 ....... ~---------------------~-...-_I!!:w. me." CcMu... ...... OIl • • 1 . 111... .... . ---' ......... ... •O---l .DGC'I.... . _. lftoIk L u'.. 1IaatIrt. ·c-ay0ldL b) AdcmI sa...t .... (MA) JW." . J• ~OCIIIIICt. Faaa...dlatwo~peced my at Do . SdIDol .'i·.......ll a!l-Oo!Q PD1l N. .~a..... If_ .I~ Y. . c..t t: 1c&(Mf'): ~ Bwe_ . ~A 019u4 3... .. Code.. ...Spea"" BuIld cemfW..toplCbc8(AH:1r) NJ 6.. JOUl'z..... LYNN.

..".. _ .tD:..-.......... ~~ ..I' ........ _ •• _........ _ ........_CAP) I _ _.. ..-- .. .......V.._-....1kW1.... wIIh..«dlldp1medfaray~cl ~&ciIiI:y.. .......t .....~-----------------------------------------------------PdIIr'C0d8: . (MA){ScIe~bQaH&:t) 9I*IlWDllk.aarJId:dIIF 19._I _.... (b)tBI'Ja(llc:.t bdwdm pcr'~-*_JQl~IImfva1 11) ... ..J4 r.. III _ la.... ....Bawc. 'l'IIII ._""".W.._...~ --------------------------------------------------PI'.. yaarabiblytopnc:llaO __ yoar.... _ .......I~. 23.ar_ ...._«p-abe CIldIaIIed baaa_ ..«_" . ...Jl'ClllPIJDCIKlo..JIIIIIcd..... ....... J2.. ....nYllS___....._(AJIj ... . ... LiIC--= . ...... _ .._ .I:DIDDIIl GlbardimamiDDr1nlflic:.o..:....._' " ..:._1IIID 17....-. . • .-1_ ~ ... been !II lpIDIt..PW' .......__ Y..-__'" . rd.... ~ _ r:atIOID far a:lllllClbllk:lll... . ..._ -_......_." .(AI? ....... __ t " fill".. Pe ·_ ..."....._ A._.._ ......_ -..........._.... alaaWCII'. . 1.-.. ............ a. c..PRINTNAMEANDNUMBBR: 10...whaIIw«_ ' __ __ • . . ...fVI_II_........ SW YBS ....a.... -..ac. ~ ~ r- • •........ . .. ph 11 .....:. .Lc.. ....ea.-.... _rI " .lIadtId.. J... tDnpGI'C · _ fII P' ... '... wI'd ..._I __ ""''' ........-(AI') ) wIdah.._--_..1rdaiIr&pqmm. __ H"uc ' \4IIIIIId _......_btId wIdaIl_ &bo~twD....... ciaqe4 Widt...."a.aaI' . a __ ~_ ..tDpw::IXB . .......cdler1l8l1lk ....@II! .... . _ t ......... 'B1111B1r ~jnqdII'~.c::......_J ... . P&1IiIrOldll= .c...... _..1I ...... .'" IL • "" ... o--..... . iD. ..._JQW .." J -".o.1n.. ~~ . I. I •..... ·M1hIlG'..d ..JI. lDAu 1• ...I 2l. _ .. ............... i) - n ..JI)(NDI'NIA) "dd' PlNmlNftiE}i4iJf 15 16a-....t.~.. ~ la-k_ 14 a) WhIt...10 ~LIIlN-= Of KIN __ Md¥e baHptllldld WIdl dacfallowilta L .. au.__......I.. MA QlMCla-I5111n11r1h2S _-......lfA. i . . .:...... -. .. a... nIaI...nMm s . wllhACItVS-.c..8CIb ... .... I~ _·_~ .q~ ... .......... (a........ ' In. . ill TJ"1ss ~ [1...MA' ~ -IIMAt.... ._... " ."CGdr "'CWI:....aRlllidld«.5) b) J_ 5 Clleat.!i...."eb· 'a. '....sa pdlii............ aal'Xaa15A ..... _ ...cJo-.:DIICIaIl:a- . 2O. _ 21.......L~_1 . hau .....-......~WIk... • Fa ... G..0ItdI:.- .. .(s..bJ'_-«~.eCll'beIIl dIaIed.. G. _' ....."".(AI') .. _. IM.:..... .wIadlbll GI' .... ./+ 5 •• DI hrll_pncIIcII •• ·.....tIIIIIt-.....0* _ 1111............ ~paaIIae~.. ~ J' 1 .. . l1..AfIDIedoW')...... p ... ....... 1.... ............................ I '° _..... __ ~ •.): O)J«1I'DMJLVBDJHDIIIIIC'l1JNDIIPA'OIIn'CADIM . lit . ' .c:wtIIJ ....JIA .1 __ 13....L!::L_ .nJUIICldliUl. ~rlRPt ---- u 9= CIMIftIcI by (a) INSORAMCB~Lar Of M ASJ ...-.....L._.~... If ·£5" 'te. ..... ...

=tlw...:.. IIdIrcoder.. if 1Df.IWId . . ... .. ~ l I (N....... 2... bnuodoabookllL to)lll"llelle __ Illdill ..-------------------------".. MIa: ~ ~ ....u.4)IY): t ( "(MIl'): SN: a.... t.~•.. .... 2) Code: I..ouIIay. 111........ ~"~--------------------------~--__.t... JntIr)... Business Address: 1180 BaACOR S~. ...0 Ob...d: r 1dIDol: Ivan-rrantav._"ftI Cf'tdIndeI'DI ... 'SI: C'..NIM..t~ic.. fIIIICInd widllbe WIowIDIlIIIIII: lwII ACJ'JYB........... SB BIlOOXLDIB.__ .. ..II••• UOS' .. ... IIA 02146 DlaotBiIth: lJc.to c-.... U)IO'O- omrwnly AmIricIn SpeaiaU:J BoIrd cerdfW...._wm .. 11111 . ... oIM1 •• cb"" BeIrd 01. itt.. s.....r-oOf Mect10Il 10/14/83 4._......_ nltb (IIe.Common .....'1111 . •Makt..w...: ZIp: uo. 3rd .........sr-: ~~~~Lm"~~~ ~ BORIS I ORKIR1 M...._AO __ O_~ A Replradon No.. 0..__.. MOllodl•• Ur ... T. a1 Dara lAIe PIe . ...... Y_OndIII..-.. aIbIr • n.at _... (Ab1r): RJ 6.. 0Cber 1IIIIlI(1). = ........ IMdIYt ....kij~1oal S..au ........aology --_--C*. a) Otb8r b) S_ whlreyau you pmiaDIlJ 1ioIaIId to paadoe (Abllr): til .. . HI_. SdIDoI: (617)277-0090 z~. .. . ~----------------~-------D.......... DIll ofBinb (111M'): s.II1II I ....... 1IdwId 10 be Codt: Drua'" nwab«('). Code: a) Pedenl (DBA) b) ._wII_..... INACI1VB _ . StaIUI Pea .a........... if aay: 9.....Iu: 1_""'" • IbInIlJ0IftfI't1llM........__ IU_. Mivil)' b. s..II II.:.._( PuD_~ ..·PIIJIIcIaa wal ~ ...... .... ..t1t~t....'~5~~" __ ..... . C. aa4 ~. .. 1... . '" fcJr"copy l pawId& boCIDm otdU. Cock PedIn1 (DBA)..SUIT. • Add .. (1M T. -... ..W_II... 3.1 . " i1111n1CdoIII en ....... 00IIp0Il....111 1. u.....D. Wilt StNet..1oIld wID .I&y: 7.....ed: .J!:... ... 1II .1". ~5~1~7uO~1~ _'&CT~~~II __ ~O"fi~/~l~a~'... under wIdcb .---- DIp camt1)O): . SpealiIlLJ CodI(I) (Sa TIbJa 1): £!!!! OBG Kola .. .

..dalrYBS _NO(M1J'HIA)"--ll PoIwR-1_R.."'""'" .._H . I(.a..c:ili&y Codo.-.. No.r. "" ...... " ~ IN ...... trilhflCllll:y........... __ ".melpractk-dlim beeft 1blI oIIia? .eumlIdy ia¥olYed in . IDM.._ _ ..__ a. of)'OUl'piIialt C8R1"_' .." ••••1.parJarJ..HmiI:Mlar~.. 7 &75 1 r..... 11.. jWU' 20........... __ ....... DIll III bu fIcilideIwIMg P8ci1ty _........yIidm lMNIIIIe: hull compleIId dIUI.ltJ.:I1:1III..1_""...".... ... . .._-. ..... " . orprelCribecoalrollld III tIIII'ic:IIecI 'bJ' f.1&1 . JOUIIIIIIC ftJ1 aa& . Unr: ~~by .... ~...been filed yw by .... .. to _H. c: tit. ~ (SeeT .... ..rieat cae in S_blJW~eumpt: a) M..... UmiIIed... _. fDmWIr or cIiIcipIined for lIlY Yiobdanaflhe ..-IIr pd Plcilily Code: _. Hawo.... " •• ....... lawIait.. ~.. (AP) (AP) If 999.....Ul IInIan: .. C'ii...••...._ _ ..... . ~ _........ __ . F8ciIitJ Cock ('AIde: _:.. ...._ .. 1ICo. ..HaYe yoo amediollcoaditicJa wIIidllilniltor 23..•• .....1 •••••• _111 _ "_ ••••. or .. " d "...."" ..c........ 7 (SileilaucdallltarMnldmofprlrury"') ~ U 24 __ to . 1..ha¥e .... ..G C. 21.iutnaDo -..N_~g..&WJ"IItt' _I~~~ .. M....10./DIIt1M: I IIIln&il&lriq widlACI'lVB __ (a-t One): (i) NotimahradindinM:t/iDdiNct. ta-*-> WWil..s.•....!L IWJIar 6dI: _ PicBity Cock - (AP)..... Cbect.. ..c.. H _...1U1l1: 1he _ Y.......... ...r. . 11'. ...lfcl UYBS m •• ' [... ... t-anduuetmnlnaJllOpmm ._ .. CIAIMI MADE: .: _ • Y.. UI__ M_ aI..._ _ __ "' _... lICIt "11 G. JD.k:: (AP) IIDiIIId . •• _ 01' _.. Hu... IICo SlA. ' (s.. )'OlIcumimly DwoIMdiD iD.): b) AddiIjmI1ho1pb111llwhidl yoIIprovioUlly WeI priviJepI PdbyCode: hIIIIIl_ ......!L...... .......... tniaiaa pnapa ...c... madicIl ~~~~. .~ __ wiIIIdmna_. 1 • hn rillG.abeallhcare codeI fJumTlb1e:4 . Il ....... or _...u.rCede: . ... ...u.1..."... _.afll... __ _ ... CI&...LypicI1-I wed .... tudIadIr...."4 ...lawIait wu ftIId in reJIdan CO __ filed...ma.... IQce.-.. . 0IbIr Ibm a medical malpncIk:o IIIit.... . &4 . .... YMU: .. JOG DOt.. JIIDY..bl t· whit. .. fII rlL .... arttri ................ ........ .Olr7. 3) PICiliIy Code: PditJ'Coda: If4'... wtUdl k to... WIlv... _ I....~ .. ..-........... F1......f_far WIll ."'I.OIIt..1Ijajaa 'I..._..... or NaIIIbr.... per typica .... NlidlatarcliDall·.... i.. ~ ••• _MM...... y" No._ ........ SA. AleJDIICllDlldlyin 13. ..._ .... 1 . _ ..-. 0').wIU ba _ . _1 __ .. _No:Z: _ ..... it ~ iDaJranI» CIIIiIr .~".... __ -. "......IIPo.....l~1ICo 2. . ..... - - I ....... pouppncdce or~...._~~WW. . (~. G.__ _.-priv&ptD.l(..... 1'... L-...... NO'I'II ".." rt..". flf: .... ·.._..i..". If .. ••• HH I __ •••••• _..1be_at _..."~_""'~_ ..!:J.._ .........t. IeIrkIIII CXIIIdIJct ill the JII'&lIic:llI of medicille....PRINT NAME AND NUMBER: 10•• ) c..._.. Mille ... Pdt. .J. ~.. modi&edorotberwite lUDited)'OUl' JCOpeolJlllCliceof'll..J.. _ DI III 16..L. wllUabiIiIJ iIInranDe.... In ...._ IiIiI:IIIiI:J" _-- in... a.. )W. _.L. 11...k .. _. ...ppIbIion l«.C ..... OJ.........7 ~_ .. .... .. '· . L (b) .. __ .. ~ 2.J lIubbca ...... ) wbidl in. 1 will fIIIfII.... 1_ 11. _ . _ __ F...._.L..dIlIndcIl ... ~ar"'_'..._H or....._ __ _...- ....MylDlldicll~1nIunaoe U..ni&yCada: H"'I~ ....... ' _ .. How.........u.. .. .._ .....I1IIDd lIlYCMBnqaireaMaII ill _Iao'_''''_'' my-.... _...it • _..... _ IIN'TIDI PAllfTWO 14..s........ I~ 60 .....vu...Paab........ II1II .n I or _.......J....__.. •• 22.prInaiptl b) Cae or ia MaMlDJmletacSea i) Ii) 1Ift..- ct. .-. taciIicrf-> Ilwbich)'OU ~ I~ I~ (AP) (AP) Ph. . a.. "'.. 1 .....L I -"" (AP) .. pdatlllQle(.... pmridcIr nIIricIed.. ~Oedk ball_ IDlOOW-SbJ 00 ---. .~ .......\ .. _... (_ iIItIrucdoD bootIet)..._..".._ _H_ .adal ...r.. ..__.... T1bllI4) iaIncdoa baotIoL) are..!!1... 'w ............._.. P....w... wiJkor do you ~ I __ _ __ M _ __ _ . ~torCMB~ Do .... a~ .s 24.... Appanr. . . in pimIry . 25..JIa. 0 '_ .............. bt 'IIIId..

. j . ".. I .. MadmaAdcNI CUyfI'own Zip CoIudly BROOILIKI....".. ~. 0raduIIed C) DcgJ=+ lID DetPw (MDJDO)Hours Per Week m MIa 6 Specialty Code(s) (Sec Table 1) Code(s) HoJp DII' Week m Mass. 1180 BBI.. (See Table 2) 7 Current American Board of Medical SpecialtJes Certification Code Code 8 Drug License Nmnbers.'.... Stale ..I. or.... ·Medidae at.' B)LIe J...s ( Home ( ) ) n. S A) Name of MedIcal Sch001 Full Name of Medal Scbool l:van-I'rankovslt:l.(MIDri) _'_'_ Sex (MIF)SS# .j lledical B)YearGnlduased 72 Institute V. ...- ..~QP'U1I..aty. Othet NIme(')..ColDmODwealth of Massachusetts Boant Tea Physician Registration Renewal AppHeatiOD w. Priar Spec.... 11 3 A~a111ng/Bome Address· v._- Code· -----I . .m... -_.. 32t -.t Street. 3rd lIIoort BoIfo-.ue Date 10/14/83 C) Sex K D)SS#' a..te ofBalb (MIlYY) __j_J_ LIe Issue n. . MA 0%111 (61'7) m~ ttoa . 1:m(DM) --------1 (0.I.. If any A) FedcraJ (DBA) B) Massachusetts· 9 A) Other states where you are DOW bcensed to pracnce B) Stales where you prevIOUsly were hcensedto prachCe Abbr Abbr RJ 1:==-· -.CCIr B~siness Address: S'l' ft'B 58 K& 0214'-3806 0Iber Addns. Slate BuiDe88 Phone (617) 277-0090 4 A) Dam ofBJrth ... OBG 60 Obatetric8 and QyDecology ----- Code(I) Ifos. \ . Cdyll'owa' Zip CounDy....__ . Home Phone.

..your priDdpII work IOCtInaT(Sec Tare . )'OI&r iaIunIDce coventp ill. of.. by·1awI or or.. "'. Naiaber~ )1 :. tp XU v NQfNOT hee'"fM Nt....... rovoIaDd... LutNlmo: O~ KI AI l~ijj"'kda&pri"" P~Cado: _b) IAIIIIr ofCnldil .:. CIIeck 'or'lIPtIpp 22..__~~~~~~~v~~~~~~~~ AilCl1Wivol".:iliad III. wMthcr or not a lawsuit WIS claim bcc!n made . youbelen ICIdod... Supply the codeIlaI (AI').. A.. pmfoIIioaal c:ompcIeftey or canduct em your eovcnp or haw you vohIIIIrIly . 01' ptJccd. fedlky Code:_ F. mpoIIIC to 11ft inquiry by a profoDioaII Uilblity . . in~ lUI ~ . C)"1 20./ \ D...LL QVaTIONS ON f4llT... • S.. realcleat or dlrllcal teJIow? (1Cboct one) ] 3. IlIN&WAL APPLICATI CONTJNUED ON PAGE 3.L: .i8r orpidad FICIIIty Code:__ ......... fIave you beat cMrpd with any crimlllllf ofl'cnsc.. heaIIh care facility.. Hu lilY lawluit..ciUtyCodo:jq!_ Jl999'.. mcdbI malpnlCtice iuurIDc:e is eoveNd by a) ~ ....looal Uabillty iuuJ'IIneo provider reetridod.. FIIolliIJCode: ..~ []. ·~ I am rcaillMWg wiU.-n'1 21. Kave you completed )'DIll' CME requlrcmenti precodiq your I'a1ewa1 dIto (sec fNbuctfoa ~ Cl W"1Iq1IIIIIId (WII¥er ftInn due 30dayI prIof to dllCotlloealcl.. put 1WO (2) ywa.t i.PRlNTNAMEANDNUMUR: 10. Propa .. Care ofpldleDtl in ~ (ICC1utructi0ll booklet)...::\ 'PICililJ Codc:_ !_V. ) 1) Avenp weekly houn ..HC ~ i 11m (cheek: one) a)__ Not involved in dlrectlllldinct patient in MuIIchuaaI ~) _ 0tharwI.... AddldoIIII heIlth cae (Sec Table 3) faciIitiea II which you prevlOUIIy bald prtvllcps or wtIh wbicb you . otbcrwiID PUT A 'Iorap m o'rrttw 11""'22 rtIer to two Ql yean . termilUded.U I?.. A. ~ blat I . (1 .wulcnd 10 or 1IIIPIIided. a medical mal:pragdcc suit. dIIpeue or preecribe controlled subanoos bean _. print pIICOfj~ I. ...".!..-. 8f'OIIP practico 01 profeatiOllll toe:iII)' or . A...*_!LLL 9:... wt.. ..ur.......s_ i lo InIIwk B... _j_JAP) B. I:Ife I! \ 2). CWMI MARIs HMany mediaa1 malpnlClice . lilnitcd... campt _ i ! 12..... Do not submit documentation of)"Olll' CMEs with your reaowallppliclUon. adler than a miaor tnftJc ~iOItdOn1 18..... WhIt ilcbe lIPJIIOXimIIc pcrcentI&e of your patient care houn in primIry '1 __ % .. other ..\ 8& A1If8WD8D.. Umitat or .. HMItl'/ pror...tjudic:8led..... F. which II relllOCl to your comt*IDCY ptOfesIionaicoaduct CUIMI """Jm.alit)'C'AJde: _ ... My F.. 01' Pnridt ' I I IN TBR PAS'[IWO Q> DAlUh '4 . Involved in: a) outpatient CIte Ito hrsIwk CII'C b) I ... bcoo filed I&8inIt )'OlI or been lICIUlod. u.> aX.... . ..cUity Codc:_ If999. 8CQudicl&ed. coactI1ioft reIMed ... .. 1Clj 11. Have youbeeD fonDaUy cbIrJod with or diJc:ipJlnod for l1li)' vlO~OIl of the mica. Haw you wftbdrawn IIllJlPlicadoo for • mediCall1ceoae or been clealed • mecIcIllioeale for Ill)' ..... -'" Nauoflmgr. Curnnt UaIdI ea ficlIiti.....Iv. impoIDd • ~ or .. MUST ..olYOd? in tile practice ofmcdicioe. ~ :&. prcwidItP 22..y IOvaumeaIII autboril)'. Are)'Ol& curnotIy ID a JIOIl1pduIIe training program in Mill. Has your privilep to . or prIaIice medicf~ or )'OUf or odIarwiIe r.. ~_ PICllit>:Code:_-....~QI\. ~ Ydaidl you have compldlld the cadentiIIfq JIIUCIII tbr die ~ I I to tItoec boalIb care fIcIItties FlCility Codo:_ Facility CodcI:_ I ...'01 en. to the clllm? 16.1rrite NameCI): II._ -.... Haa IftY modlcellllllprM:lico claim that has bean made .. ~~km~:. denied or I'CItricted by lIlY Itm 01' fodera1 .d by e-:icII 0Il'e _ ii . .t ".. Table:l ..... 19.. filed In rcledon to the claim? you that hII DOl: yet beII'I ftDaIIy ICIIded I'CIOIved.. wWlcr or not a lawsuit was filed in relation. Sec InltrUctions for eMS icIqujrements.

-.-.. .· .!I!J_ .lilir··· . .:.-----.· u ••••• ~.L ido~· ~~ ••• l' ~it'~ . -· Mass License ' LicanIc Status ~!@ a·1701 " . (pl«lst comit as "tctSsory) n....----------~----------------.\ ..... SPECIALTY Primary Specialty: BOARD CA'DFlCADON Obstetrics and Gynecology Cortifyiq Board NIIQe: ~. Homital Aftiliatkm 1180 Beacon at....._ Mou an.B. EUaabetbt• Meclical center N ottb Shore MediCI! CeDt. ¥A. _ . SUIN _ _ _ __... .-J!JI.N.. --_.I.-tr.uu•• __ •• u. t'O'!tctitp toa?wwr ft1n~ ~_ ~ _. III.. First blue Dlae llVJJ.1.~ ~ . .G_... ~ · _ __ _ _ .11011 'II .rofll(f) _ _ ------ ·-MIfiJir--·-·---·-----·-·--------------sJt1...Jt.. ••• ••••••••••••• ~ uu u. __ .. ._ __ __ l2f¢. Ljcenscs Held in Otbor s..... 0214&. .J. "._ _ __ IWiMlrcyPro..._ ----JiQ~z.'b. _ ...:J.· In'CIAN INFQRMATION 1 14177.... ·._ _ __ _ ~'. mucmON" .~ 'n _ ~ _ -.u Moke oddl'GS COI'f'eCliOiIS Mre: ~ .···-···-·········~~ .._~.·········-·····--·-···~··--&~~'_-'-"""'-""-"'-"''''--''''---_'''-''-''lii/JIi---''--' .--JJt~1J!l _ .II~~~~·!~~~·· ··Jili:ifii'~iiiii''Iiiiii· DAINING -····-·······. . · Dyes ONo .S. ".... ate 5B Brookline..LIl _..Q090 8t..:1~. lbpitU ~h 1~w.u 'myID"" Plan Affiljation.: r: ....·······-··.A-cJ:!i.... . .. _. 01". .--.. Specialty: Certifying Board Name: MtJke tl1fY ctRf'eCd(JtIJ Mrt: .= -v.~S.u ••• ·..~-:...-------. I .. ~ _..8806 U.A (617) 217.-..et-Sa1em Hoep Faulkner HOIpital Newton-WeD...::_---.00e0 "~~iM""'''-''''''''''-'''''-'-''''''''-''''-''''''''''''JlJdJIt·1i. ~ u ••••••••• - ...

._ Uh _ _..._ ~ ... NH 03103 """'.. ..flNe..0000 OldeR issued by the Massachusetts Board of RegIstration ia MocUcinc. 8030 South Willow Street._.~...u •• ~ _.at time._ _ ••• _ ._ __ _ _ _.. vn.h·~··· ·•··•.....~mL _ _ . •• _ u.:)... MInchOIter. ... CJlIMINAL CONVICTIONS inc1aded ".... n ". 'It .. of Years in PrIcdce: #J p. _ -_.._ _Alo.. 'n . _ u • _n __ • The Board ofRqiltration il uMble to obtain accurate data far this ~..._ _. _ ___ hO _ n_ ••• •••••••••• •••••••••• n __ H ••••••••••••• ···. Awards.--._ -. PHVSJClAf9 HONORS" PEER-REVIEWED PUBJJCATIQNS Please ~ any peer-miewed publications to ._ _. "..:~ _ No._ _ _ .. at the pr. .._.... .. __ -... Pleue list any criminal.. __ ... ._ Date:::::::=:~::::~:::::::::::::::Amount _ _ :::::::::::::::::::::::::::::=:~:: Datc _ ..... _.._ _ •• _ _ •• _••••• u u _ n _ _ _.which you have contributed and uy IWIIds fbr COJUIIIDi1y Imic:e or profcssiOD8l ~jtion you moe been given... __..._ ~ ._ •• _ _ ..... HOSPITAL DISCJlLINE Ibpjtal (JONe: VI.4 __ •.u._ _ _ •• ••• _ _.._u•• •• _u _ _ _ _ t _ _u. This iRImDIdon "ill be the c:oun 1)'1tc:1I\ is fully computerized.BOUn mSClPLlNE Final Decisions and 14M7. Nature Date V...·_···· ·__ __ u.. Basis for CoaapIaiat _ _.... ._. Honors . ORKIN Dale =. 4 •• _ •••• _ ~_ •• _ _ _ _._ u _ _ .. )_E:_...tum cI....__ .U..--..-...::. Inc. file ._.._. _ •• •• __ .Ii. VIU... uu u •• ~... __ ••••••••• C 4 ~_. DaIe . __ __ ".--... or . . 5E=:~~~~~~ Basis for Complaint -_ Basis fbi' CoIIpIabd _. .. of COI1IPlaipt . h..U _ ~.. MALPIACTICE Details of claims paid fol" Dr...-. Atnouat Paie! Paid AInount Paid AInount Paid =. CODVicttoDs._ 'I- _ _ "I •• Note: Atlantic Associates.. ..UU h ••••• ~ _ ••• _ •••••••••••••••• n .....·.H···_·········.. IDclIde CODYk:Iion _ and D8lUre _ ••4 _ NO.-._ ..

. -_~.t.. ifill)' A) PederI1 (DBA) B).. MIdIrDe at...!!!i!!!!!!~!l!~5!'!!~ 0Iber N--C.... DIIIJ'II CI yo.need ~ - for _ '...8J:rdl I -.. %ZUltltute Full NIIDe ofMecbcll SdIooI' IvaD-ftaDltonltij . o ActIve chIqe your curnnt seams. T _ __ Other~ Crtytrown ZIp CCIIIIdry -I' 0 BulmwaPbo...) (See TIbIe 1) QyWtl MIg 08G IIsm-W_._ B) Business SOZft 58 BROOKLIRB ......I o .•• • Copy CommoaweaJth of MauacbllleUl Tea Wilt Street. ~. 8 Dnaa Lac. 1180 BDCOIf SftBft Address: 02146-3806 .gAd&w crtytrowa Zlp .. or. - CocIe __ 1 1 :Jn.tSlalul _-.. tee....&..lll~ ~" P I -......s- OM P ofMeclbl SdIooI: Ke4ical .. y. ...- Befo .....me· lID 6 Specialty Code(..... ~~ U1rd...) 3 A) Mai11Dg/HomeAddress: .. lUke corncb••• (t)'pe CII' ".128 Physician Registration Renewal .. .) ... please mcitcate. (see below ..i:"~-·~(::\'i~= I eun...... fee ofS25M... 0' BGaII ....ae 4 A) Date ofBu1h B)_ 5 A) HIme (617) 277-0090 Home Busmtll ( SS# - ) (MIDI\') Dae of.... below (Check one) 0 RetIrm& (see mstructlons) 0 Inacbve... SlID Coaatry - . no. B)V.......1'. ~ ~.' ...." '. <lnduIacI 1'72 Clne..... iDMI .. W..... _ . •.. ..... aDd Gynecology ---If08.~l'Mddle dus fiInD IIlCl aIlllblCbmClltl loryom' own ~ fOIl w1Il. CerUfk:mon (See Table 2) I~O*L\) ICD_. . e~d...:~ I Mluba.... GJ.... . 1:--=. 51701 WIDt to Reaewal'D..trio... 3rd JI'Ioor • ..Plmt Code(I) SpeeIly 7 CamaI Amtnc:ID BamI ofMedbl8pecJaJtael 'Code Code. "'. Board IrA 02111(41'7)721..lluc_ for .ue Numben.: _. . • . RaIt~ ~No Ifyc:m • Add ......:... 60 Ob....

mcdlcme.ac:. to tIae beat bnledp.. or p1aced tIDY c:ondJ.":1. y- ! ... WITH YOl.... · I.. G L Co IU...O (AP) _ % Facility Code % Facdrty Code by a) $~.. m dlrectImd1rect 0 0tbe:nnM: exempt aDow'1 (dIec:t CIDt) 0 Y... llA... .-_. . (AP)_' (AP) _" _" hcIbty Coda 1S. lDSUI1IIlCe 15 eovercd 11 My mecbcal malpractace pO (107« InSIlI'IDCe CImeJ: b) 0 . obbptloa to report of......lcated.10 Cumut IwIIJth care fIIcJliUeIlt wIucb you have eompltlteci the cnwJrGttehnl awoo-fiIr die pIVVaGa the c:odes froID Tablo 3 and pIace a check mark next to those health CII'O ficdaUee wbn youba¥e . heabb care fiIcIhty. SIpatIn ... ... ..1 wII ftaJ:ID ... wbelher or not a lawsud: wu filed m rcbdlon to die clmm? 16 HIS any Iawswt.~ 'O M_d._). or federal appcy" 20 to or IUIpa:Jded. ......:::f • !L~L!_x (AP)'Io. C... UIIpOIIId alllR:bqe. tItM 1M II . lIty. ·l .... ~. _.. bIMIIr:IIJy .. .L.1 I (AP)..__jL (AP)_% If999.fuatJ •.. or your ~onal conduet in the practIce of.....JUd. •• 1'. U . demcd or RIInCted by any ... f J" 1wdlllOt eIlarp to or c:olllct hili • M.._.. IJlPIOXIDlUc perceatqc of your patJent care m pnmay CIl'8? 1Q__% PART A OUESTIONS'ERR ONLY TO IRE PAST TWO Ql YEABS 14 Has aDY medJ.....Q_ . tamiDlllld.. been filed apmst you «been IeIded. . you been . -... hmI1ed or temlmatod your msurance covenge m dIpOMe to.. • or_of . leUIed or ~ CLAIMS MADE: J 7 Have you been dIII'ged with any cnmmal offense.. for a mccbcalliCClDlJC or been dented a medal ~ for my 21 Hu any protWIlOIJalliablbty msurancc provxlc!t ~ luntfed. or c:o-paymeat.... . have you voluntanly reaI1'1CIed..J1OCIIty or ""' of •• wm" 19 Has your prtVtIep to possess..ISlA 1110_ ~ iJ. o1hcr dum a mmor traftk: VlOlataon" 18 Haw you been formally dzupd WIth or ducIplmed for any VIOlation of laws.. bas not yd boat fiDaIJy whelbcr or not a lawsuit was filed m relBbon to the clem') IS ClAM .. -.. ~ (I' otherwIse reIOlved? ... an appbcItIon.."....Do aot Hbaalt dOCU • Pllnaallt . c. Have you Wdbdrawn.J_'i. 12 Are you curreatly m a post-graduate trainmg IS m Massachu$cUs • a MSadeat or c~ your prmcapal work settms" (See Table 4) B Caro of plbeDCS 2) What IS the III MassachuIeUs (see mslructJon booklet) I' ___ Sf No 1.... nIoI....t. Nat to ~ FIcIItty Code . '. - l t t YOU MUST SIGN AND INCLUDE PART B. ...eA.~--:- • ?"'<>J-7-o/J"'~"''''-.. ...... .. fIlCh facility... .. or othcrwJse reeolved..-r-~...mLVEDj Has any medu:al malprac:tlco clem 1hat has been made .Co 10....!L _Jt~_j... by--JawI or IIIadIadII prICtK:e of my govcnunental autbonty.. • ~ G....__ DD . .ll RENEWAL APPLICA110N' -'9t"'T_....... ~hrllwk b) JDpIbeGt I} Avcnp weekly hours mvo1vcd m a) OUlpatIent cani h<)un CR3g_.. wluch II related to your COIIIJMIIalcY to pncUce IDICIaID.. 0 No boeaIe apa'Ital) 0 CMB exeaapdoa ofyoar CMII WIIIi)'Glll' ..~ C...B « (. dtspeose or preecnbe controlled IUbstances beerlsuncac:lel'ld revoked..cal malp1'8cttce clun been made agamst you ..w''' t M·. ~" ..d.tion re1ated to professt<mal <:OD1pOtImcy or coaduct OIl yoar ~ .. G.... othc::r than a mechcal malpracbce swt.. mcpary by a profeIIbIIllllbJhty lIlIUI'IIlC:8 provKIer? reuoIl" 22 o CME WIllVa' requestDd (CME waiver form due 30 days pnor ~tD CME CUWCAIION: Ha~ you completed your CME fCCIIID'Cl'IlCI precedma: your nuewal cIdt1 to dDI of See JaatracCIoB tbr eMIt reqatremeata...aIod. -'_(AP) _ .. ad.qund1lllderlaw JmII: ...ad belM.. mdICI&e ~ fb1IowI IDIInDCI I am RgJIta:mg WIth ACUVestIdus but I am not covered by mcdJcal DIIIprIcbce (check cme) ~~km~~~ 13 A What 0 Not mvolved..L. or .lb Itate ...... wnte tile ~perceDtIge ofpaUent care hours dull you prowIem IICb &ahty FaClbty Code of .. group practrce "prDfeu-.D w u. ... tatuer. Name of Iasun:r a) I} pa11ent caR m Massachusetts JX"OgIIDl .. b) AlterDllbYe1y.... becIuIe 1_ FKIlIty Code __ Leaer ofCnmt ...__j. -.:1!...pnntD8lM(s) d&so......

... on ""'1 JDII wJIl • Remat$lSU8 for ~ _ • Add late fee ofS25M........ . 3rd JIJoor. 6 Speca1ty Code(. - IH~. Before proceed.acildyCode:~ r. -'_ (AP) __ " .esaewalDate CJIDN eneIope..CommoDwealth of MlBlllleltusetfl Board ofReglltradoD ... cmm. 11 . IICt:IIrttey 1UUl~ R.. fpr)W' lIl1IItbe nbInIed ....l.. you lave .... . __ --------------~----' ~-------------- Home AddmIs......... and other parpoMI...tII(i. _ ..O' ... .3?_tjt(AP}_" PdayCodr19-..... ofMedJcal School b)~J~~MD g a) Other ..""'''''''' wtrvrtigp bggld4 Copy thII form .~ ZIp Catytr01m __ --:::--CoIadrv __ ~~------ Home TeJephuae PLEASE N01E: No P..-... please check IZlH of tile foIlowm& bcwIa (_ to mdIc:atie youram. pmIeaII (AP) Next to eacJa ftddy.....J ad place a c:hcck milk nat to Iboee beIIth em ~.._.. MAUlll (617) bUp:I._ . Up..(AP)_" . -."". Jfany... 0 Rebrma 0 Inacb:n 1IIItrucbaIIs) 0 Do 'IrIIh liD zaaew _ 2 OthecName{s). (»)-0...J procell_ ssu: jtr-.) Fedfal (DBA) b) Millin_ 5 al N......eaVdope. MedlelDe Ten West Street. CIm (Slipply die codeI fttaIIbk. ...ActJve wmt to chmae yourcurrent status.._ (AP)100 % p&CJbtyCode.._(AP).. TIds eompleted renewaJ form WUb .-- b) SfIdes where)'OU ~ prevIGaIly hceaIocl (Abk) 10 Cummt beaIda CU'C facJhbcs at wbIch you have compJeIed the CJNknbalms die plOY'" 01.....( l"t before year renewal date....... ........" F. 4 ..lD*ofBlrlh c)SS# blSex M 7 Current AmeIJ...!-% PacddyCode __ . ..... VB taTe .~ m-3t16 J Physician Registration Renewal AppHcation need eopl_ for enden ......Ca Code BoIIld ofMeclaca1 Spraa_ Ccrtdkatacm (SK 1'IbIe 2.". WIlle die ~ pe!OCIDIIp ofpllbcDt CIa hDan &at YGII pnmde lIIadtllmJ:dy) F-*yCode Ftal¢yCode 'f999... If aeceumy I _~ _ .. pr:IId:.egastnnonNo (tee msuuc:uous) were bcensecl 51701 -... .... ~.Ulderwluch}'01l PIeue mab CIIITedIeu (type orprmt) OIberName(s) CUyfl'own ~~ ~ B) sr. Mde 1119 Ctll'M:tlllIU 06Il2l2OO1 (Qeck only OlIO) DI)t til' X 1 C'um:DlStaIus Acbve R.Jl... Retara raewII • EIIdoIe daeek wd:Ia • PI«ue ret'iew t:iIrt{tIlly dig foIlowillg illformatitJ" lor IIItertItitnu 11$ ..) (Sec Table I) Code{I) Boun lIS' Week m Mass OBG 0 n -- where you are lOW' hc_ed 10 pncI1Ce (Abbr) ~.Code If my 8 Drui LJccme Nambea......

_ .4..· 11 My 1III!IdK:al:malpacbce .lI. . JIISUIIDCe lOt. m a~ 13 A Wbah.QUESTIONS Q="eu 14 d BEml CIte _'" jU... alate • fbJlowa I lID fCIP*rmI WIth Actlve Ita1uI but 11mDOt covered by medtca1 D!l1pAchoe ~ becIuH 1_ (cbDct ODe) N.. byMaw.. wdI .. uaw. hnaat.U DIlI_.. Do DOt . whcdaer or DOt a laWllUt wu fiJecl m rellboD to die cIIm:i'1 16 HuID.u.. oda ChID amadlCll malpDcbce _ wIw:h» m1Ided O'i~ 10 paC:t... . doeu .-?H~ ....... m..L c..mpeiIucy or coadact you vohmlInly RICncIed..7-·::.62C. covered by I)... .AIMS IfA. _t ParRut.7'-~ . NO (fIOTl!h\l laM a Cm Pnmde h' .. reImd to profesaIoDIl co. (CME W&MIf fmm due 30 days pnorto dae orhceMe ~_ 0 om 0 No cumpUoD See r. an~adlrllw.u.. hmitod or your JDIIfttICe cownae m ~ profiwmna1 t. lmD" DIt.. .... Cd . at M' . M"..OlatIon ofJaw1. .""... ~ *' . - t)Averapweek1y11ol1nmvolvedm a)OUIpIbentcare ~k b)mpmmtmze 2) What II the ippI'OXImlte pe:rccmtage of your patlCDt cue houn m pna....G........-..400*.' .. . MIt _/_. J'tTI'8 IIMI""""". ". r...BMBln'S BUOD IIwL".}' laWIIIlt.....IIIIIban.1 ..L..... Al"JCADQN MAILING. . mecbcd hccme for Ill)' reIIOJl9 21 Hal any p:oftI8maIJ hlbddy JIIIUIIDee provtder lClllb:wted... htIMId.-:-~·... or your pmf'-uw1 c:cmdDct m the paetICe ofD'ltldlcme.. .aQDI 22 a. G._.IIIChu. grClda o=t u.PRINT YOUR LAST NAME _~O:.. medicine. A1TA....... .ctfna..."....1O die clam1' 15 g... 22 Qf¥s:FBlVItADON. b)O 0 a) 12 Are p~~~-----------------------------------------------------00 you cum:IIdy 0 Not mvolvcd m dnc:tfmdIrect patIaDt cue m MassacbuIeaa 0tbenrMe ..... c....QJLc..c".. a ~ co-paymt.... 01' IUIl'eIIdeIad to Illy stm or feden1 ~ 20 Have}'Oll WldJdraWll8l1 apphcatmn for a mccbcal hceaIe or beea demed.t. ..lJIf. aL el11..._If....".IO..lmnted..C. been ell" 14 odawIIe reeolved? tD... resIrlCIIed by... or.. .... ". XpPa UUWM. mica. to.. bemallldecL ac1)ucIntDd" or c6erwJIe maolved. :.l . placed my coachtacm. 0 . o CMB WmwrrequtRd __ BaveyoucomplelMyourCMB~precedmayourl'Clllftl. Has my madlCIl malpmctlcc clmn·bccm made· .......".. odlcrr than • mmor UIfIIc vm1Itum? 1mmn""" OIl your turtluqe or or hive 10 . CldMSIqIpott. GL ...'" YOU MUD' SIGN ANPINCLJIDEPART B.. bem IDIde IpIDII you. ) . ) LlCINSI b) NllIIID: S.c.~_. ""J/. x .I2.. remdeat· or cluucal felIow9 (cbeck 1db... ~ c' Leber ofQwcbt oflDlurer ~..i lDtuamce em. ~ I MI_ I..... ONLY TO Ql IRE PAST TWO (2) DABS ddpIdpgt.O!' cbIcJpImed 1br any VJ.... mqmty by • CO¥.eA.ry care? jQ_% lfl_lDtIwt PARI A . or .." .. haddt care faCIhty....AM BgoLVA..J4 ...:..\(. ".. . mrobd..lll....:. 'IUIbonty..."a.../IIfIIM • Co ~ ...cn.......lwIlut MMIIc:IaUltfl ."_. !to i'i'JWtoovJ. your pr1DCJpIl wmk f:IauImS prcctaD1111 M.. . chqcd with any cnmmaJ offense........dIoatfGr OlE nqub--... m reJatwa.. MAKE A COPY OF YOUR APPLlCAll0N AND AU.CMIII ."... ""..--1IIIecl ~ 18 Have you been cbIqJcd WIth.. 11.... .na...114 to .t j' 00. AlIematmly.' SL4 ... : . Bu my mcchcal malprIctace clun that .J.J:t:a.y.... _1IfIIII......deIacd..Il2... • ...... tpm .. m E111.".III' (See Table 4) __ (lee IDIIn1CCIoIl booklet) GB) Yes No B· CIre-ofplbeatl m Ma .._-_.:Dt. .bdity JIIIIIDDC8~ 17 :fIaft you beea.... tiled. er . group pncuce orprobnoaal toe:aety or aaocaauoa" 19 Hal your prmJep to poacu.. you ChIt bas DOt yet beea fIDIIly IJCIttled ell" ~ 1Vbedie:r orDOt alawrmt wu filed. 11. dupeuso or pnecnbe COIdl'OJJtxt aubsCaceI beea IQIpCIlded. ofJDCbce of my gena iUi .. aL.

"". 9. Medldae w . 4. NfIllre4. a--''' ~... Code: .. Current American Baud otPtfDdicaf Specia" Certificatioa (See IMJ) 8. .~...~UI Obstetrics and Gynecology ~- you 10. Next to each facility._~ ~::8 ... fee (IIOII-refwadlble).._ .. ....ClllapC"--beJow) CitylJ'own: Mailiua Addroa: C4untry: Staee:' ..Drug LicenIe Numbcn. ....."".. 10 reDP' trUlY under wbich you were licensed- BORlS I ORION MaJlinWButme.... ._" PIdftlyCodc: __ .:St70t Ql(t bDewIlDale~l~ olcbe toDowiat: bema to iadica your _ (see inItNctionI) ~ ODe) (see instructioas) 0 Inactiw 0 Do ....0... " 1.."......-. 1'IdI eo . . aad otIaer P1II'pGIM. .) iD.... b) State• .... .' Zip: BuaiIeIa AcIdrea: Cityfl"01m: - B) Home Address: . PacilityCode: FlCitity~::gr_j_ If 999... Salle fG.. MA Ul18 . fIMI«. OItIJ_ .leted the cn:denUItins JIIOCIII fix the proviIioa ofpidlm care..-Fac:fJiCyca:jjJJ_(AP)_% ."...' __ No alIItiIticd:. .. elM..tig.... Address: o Other NIIDl(I) o taa. tICCIIIYIq I11III'.. State: Zip: Bun.... Ire DOW lictaIedtopncdcc (Abbr... _.... . ~ (\{I 4t . 3.. Curre~S . pleue check 0 Retiriq i Active ReptratlonNo.I!....(AP). -r CoaDIry..... a) Other ItateI vdsereyou .... write the IppI'Oximate pcrcell1llse of patient cue houri dad )'OG praridc in oadl ficiIity).awI II·.) ~ Beron proceed .. a) Date ofBirtb: 1.) (See Tabk 1) Q8Ul OBO o Houn_W_ M.". _/_ '_(AP)_" (AP)...... Specialty Code(.:.. if~ a) Federal (DEA): b) Matachu8eUI: c:) 88#: a) Name of Medical School: lvan-PtankoVlkij Mcdic:a1 Institute c)Dcpw: b) Year GnctaatM: 1m 6. illfotwtllllM /... To1epbaae:( ) -... beCore.. :'... -De IHOme._ . for .1t61 H flIIlWNJ4lH ytIW""""~'" '. . ::--- _ti...... Physician Registration Renewal AppDeation {. Lilt all ourreIIt beahh ~ facilities At wbieh you are affiliated or have con.l!_ {APfJ (APf::=' % FlCilityCodeS~t . CagY ddt...D... BoItOD.. A) Jfyou want to chaap your CUIteDt status... reaewll dlte. ~ t (~oaly wWl "::'d ... pnat~:- u were""""*"If' (Abbr..4.... HomsPbonc: BuIiDess Pboae: (f I TJ .... Code: 00 State: "'''NODICIUIII8t be. ) ·p~ . •• ' ' _ .. =..~ -< '1'1 N N ~ ~ I'I«IB MUw CIIlWjiIIIy tilefo/kIwbI... (Supply the ~ fromIIbkJ and place a check mad!: DCXt to those hoalth ClIO IIciIitiM wbere . 4. Other Name(I).. .... tus: o Acti\'C 2 .g... % FlCilityCode:~P_(AP)...... . aeed ~ for cndeaUalDI IIBLeaveIope ... iMtnu. _" _ ..".. Couaby....• S60 IIarrltoa AveaH.......... .._ bIW tAmIItiRa priviJcaea.(lil7) 654-9810.. lJ!J. 5..... bUplIJwww Commonwealth of Massachusetts Board oIReptrat1o ...) -....1''''00 9 V b) Sex: M Cityrrovm: Zip: Home Ttlepbaae: 1IIIIIl . ~ .

PRINT YOURLAB'f NAME: lOR..... .--G)'II'_tIIG~. . 1 ..... (lie iuInGdaaI)..... pilar tD __ . 1IDder O.ar~' . ... 0. : . "LUll • Punuat to O... ruIee.. <WJMI M6QI Of'" K~=: )"If ffIIIII)' IIUIe4 or ... fIl) oryour"'''_ tIIID...l1iabiUty§$pzoWJer «pJIcod mocticItJicoDle orboeD dGaIed I medicIlu.. JaWRft wu fIIIcl die.". 1IIded... 62B. . 00lII [t[ucy eaaductm tbejlnctico ofadfdDo.. ...ypmfillltoa.. whItMr OJ'DOt._. 01 odIerwiao NIDIwd..UNmOJ'I Qosk_ 0 IDaatiw ItItuI Cl '!:( v.. .woaotpllklltClftlJ9uDat coqt .. • 1m.. ..".... wMtbIr m" DOt .. .. tJ K: i tV 11... 1'IIIIiceed. bat l. . to.. 30. (See TMle 4) for die pv. .SIc.. Have. ..limlmcI. AbIImtIahtly. aay vioIadoD or ... SJA filelClledale 01..._. """s1l1le..L.... JIOUPpncdce 01 pat". Sec 1 I uwtea. wDl DOt cbarp to or coDect i'OIIlallecllcat . ...... 62C. widell illIIIIId 10. temiUiq child nppOd pl'Mat to d... of ... to 1M oIIiaa? ..... c.. 20... ...... facUity.. 119._.I........ 2. tiIoMl I ami\llil*iDa whhAcdve .......1aWlUit WIIIW.. Hal ~ )'011 -...... to 1l1li ftIiaIot ·M . of .... msr"" becIuoIam: CleckOdo: NotillYol\'edill~...e7 15 ".." alllDUld.RJP&r.. _ccmiIed ... .... Have)Vll bee cbIrpd wiIb or ~ IIIJ I'MIIImI!l'lDl ~. .-tl PIIIl8. 49A. am waiver roqa mutt be nbadaecl at .1Iwd Dl'f obUpd_ CO 1'CIJIOIt'" or IDd die paIIiIIIDat fiIr taiJIn ocaply.. lmecIifaI IIII1practice auit.._. MAXI A COPY 01' YOUR...__ HllIIl)' IIIDIticI1_Jpnedoe any=ma1pnIcdcc. orWeal...... 18 RIa c1Iimtbat -4udic1S1d.." 14.. fIIad"'''' ......_.... __ COYIIIp 21.. .. 0 No "'I . c..· Wbat if your priuCipIl WOIk aeatstJ1... ". HiM.. 11M.'" to 18. Soc........""'~ ..- (SoI ~).._iDMa' •• IFI" [] A .. ~LiliD .tplnaI otra. .... fbr .... ).. __ or'" U. 11'25' _...L c. ' ....0000000000-JGIl ta nap ••• tD • .. . fIdcaIie. ">' a "'" ...ri.... c. beIbh~ 19...tlDl1l11l. talftlrDl"pa)'IlIIIdotlll M_cllullUl .....~1DIl ..... ~ ... iDIuI'IIIqD it covered by ... bcIoa odBwiIe . .... 17... 0 CMBW...-- 61 tal • (Ieqaired)~ To:___j__:_t_ . lOprofeuWu} ~ ~ voJua1uily IIIIIricIId.prtYIIIp reICrictId by.. aad wfIhhoIctq.. _ • OlprllCdbo CODIrOJkId .......... Han)'tID widMImm_ ~for. UIY Inait. limited . . Do_1IIMIIt . » "g _.... RII...... _ tMiIIIy • .. ..... Ibat I !lave complied willa alIlnI at.....L..&DS1lfl Ha")1Ma~Jtlecl)'OUfCMBreqairemmta~IIJ"' . Qll...._DOt . 16..... ... _. See IDIb'aetIIDI fer om waiver ... 'm DdI. 11fIWIity iDIunmce lerDlilleecl your iDnnDoe . ~ .. NUMMPt CmiIr [] IAIIIr ofClidit PaIioyddll: PIGIIt __J__!-... IfJlOD'" Mad. cgC..." ~plrJlII'Jdalt"'IIIf""""'_ SJpan: r: II."... ......L..... 1IlY_ IR)' ..L.APPLICATION ANDALL AlTACJIMDITI DJOIUt MAJLnm.CMI!t ..... liZ. 112.......... • PuriuaDt to O.'11" D~~~~~~~~ 12... beIIl cbIrpd with.. OL Co • """'10 G. My DIDdica1I1111pr1cdce ... of"...a IaIuaDce ua:r.

. ..).~i.. 14:'._ D-a...8MCXJN S1'UET ..'... "... or '11..... DCId . ...) .........daOck·_oI ... .".....t_ . FAI 1. ·· ...... .. ·i8aw.. "".--- . . ~..~MA0*6 1lJI'D.."~ JJ. . rWA 1) c... DQIcf.. ftIIM .....r.. " .. C·.' ':~f . '0·· .... w_ MIfw... ... "".....:. ...~". .... .. .. _ I I I (011". I i I ... ._ : I DOo. . "... (411)t1'1-tOPO . JDJd1c1ae -..." .I ........ ------..- ...• ).: tl _./ .' .... I ....t· OC~"/JO" ......... I te)IOJ. .....1741 ••'" ~I' ' ~ 01.. _ .....

'" 111" ... •• m •• '.-.. _ tIFl.. ---NJ . 0 ...........otwt...._J... D '1I)On" ..". ..".tIt-_ ... .......4J a.............w... .. ' ... ...r.... II NeA __ . . Ii I._ . ....... t Cr NaI . 0diIr StIllillMllt'l ......... . --.c...... ..'J..._...".... _ IH ..." ~.4J 7) DnI...: "._:_Wwt 12) ... .... (II. I PriDDipIIW . c...... .. .. IIwoMdIl::a) . ..OC("I'ot.. ... • .........a. . PAl 101741••"...MI... _ ...1aIinIct ._..........t:Iy .....ti rnlafll .L o ........ _ IOaisJOIUOJI ~"........... a Mmkd.. ..... ............ .' ai) n 0 c C ~J»If..' en ......to:...... ~L a-...... rr 1' 01.4J ca _~ (.... .... .. '0 A __ c. . ar. .......... -....... "...1fI...' ~~ "r...... . '0 1_& ..._41' . . ~".. " ... .. '1 ..."..........A«(PICA) .....SJ CInfII' . Qat............. ·(A*) ? C 2 ..!L..... ~~ I...........----_ . •• 1 . Massachusetts Physician Renewal Application ... '\..4J ~ JneI DIIIaI.... . ." Ca.... c. 8.. .......... .... .......ene ..---------u.....clar •• .........f(... ". ....."-0IIIc0 . " a.1 _Ia) .(1' ......."...... CIrrier: CIOOO #=I.. ..'... ...._......... A..!L1nIwk . . .. ...._ .... .. - (M1Ir~ _ .... .......__ ~ _ . Sf.. -...........Not~ o~ ...... ....... '*-.........._ tB-1tIItIwI"""""'. a......... •• r... ..... ...n..£' ......t ...1I)0CIIer a)11 an I ••• : 'b)""(D1!A): """~XS: ................. ..Totta..... ....Mldfalc.._....Mia: ~ o . ..... .. rn-~ ........... [••"* ...... ..... .... .... ....~ Eh .. 5 ......... ar. .....1 ..~..... •.....I..... 10: ToW....... 14:'. 0 ...... tI _~~ 30. fweIwk ) a.... b) ...". .. .. 1 " ·r ". ..

ICdc.J ) O~..".....I...-iI.... IE... CHAMa .....' . ....L t)JfM~_Cllllflldwllll. ' .............. If.. .............."'IOOT .. 2I)CIII CD... J...._.. --. fl !.. ...cEIIC.. tllWl ..........Vd_I .. ..... .. P II Rta. ............ ................. AdJIIf • .. ~ .........."..... ...... cir ....... ..... .. _ IO .".......'" ~ ....... ~ 811..... .-... c:LU*P'" JIII ... ...... q. u.. .. ..(uI...IIICIIwd. _....... .... .... ............ . Iut-=... ......" ......... __ .. ........../IIIJOt' 14:It IPU 1.......NO PIo¥fdt AU..............£I$L .__.... JoaJCJN ilM v.... odJertlllli .... . ".. . .... ..yao ... ~ ... 14a.... 11••• 11.... tw ...........I_ ft....... ..............:-j_SJ .. ~. III ....... J*Io:df ....a...... .. CM& • CME _tw dill ....... II.._ a............ . '....... tIit .......... ...U.................:.. JllllllceofllllldJd ...... t ....... ....". .. ..... .... '.....a ...........'J'IfICA'fIOIIk .. b)It_ ... ...... d •• .... .... "'""""...fl...... IJiiIOt .. I1)'... JO..r .. I.......e.......... dllflCla . ........... •• . .. ..... III.........._JMDI I)Nlw:HIf ..CIlll . . .I4. 21) ...... _......... . WII ... __ _ •• .................'4.... .......... ·... r..( ..IJ 'C 0 RIIJI ....... .......... .I.... . ... .. __ 0) If.... Il ..." .. ' · _ - " YIiS.... ........ ........... )iYtl'O ~ ._ ___ lb'......._a... ~usetts NIaer .... Physician Renewal Application . ..:-=:............... I. ." .....tIIofpJ ... a ~ _ " •••• _ ................. ........ .. IIr_.. .......tl . .... "" ... .... 1O)II'ICIIIoe11"11 II..ot_..pI. ". .... ... _ __ ._..... ... .......~... . f • ... Iwd: .. JIIIIdI .. ....... 10....SJ ....... r __ ......... i N)OJDIlCMLLAWIUITS a)Nfr............... 10..lle ........... " .. .... .. _. ...... ..... I iI '...... . ..···· ~...........!:o--.._...fa (I......~...· 10.. ...........11.....orInIIIIJ ~).. ......I...... . ... ._ ...... ...... .... 1I J•• ... ................ ...... '_........ '7) QINIIItA...... ....... IIIQ' .. ... 01' ..." t~ u-..~ ot hIla1...... . ... AQtE._~.. ~)~Are .. ........ ........... __ ... ....... IIII . ..' . .......'........... ... aew IJ'he. ."....)...i.. OClllct ........ ............dIrt ........ _................ 11........ LI11 ................ ..c... ..

..uc_ ....L... ~ 4_ ..... I'-!e J NedIcn . to 112...' M _atcllll ... . et... ...1tCt. ..•..... . o .. 2......A. Jt•• 1II•• b " Ol-l ......' . ItG' o(.. ... .... _dN toG.. ... H2o'" .... .........11. G. . lOrtpIIIt..... ' BovcI of-.& YJoIIIeII. . 6.. . t C Massachusetts Physician Renewal Application .4M. 0rL.UO It 2 . ~J tochlJifilc .1 c. _.... ." ...... .. l'ltG.... 20c)U.. .W ..-. ..... " III11'••• ... ....... _ •• _ ... ~ ....._.A.. .L.......... .......: . It2.t. 2)1. .. c... . -.......... I 'III ._ l) . eopyotD. 5 • . J ' .a..ProIJI.1)1._I -...._ 1 . GC. t. ~..._· ~ ••• ~ •••.Lc.. . . 4)''*'''1 S) ... ..."..s ...1111_1. IIJIIJ J IO _to....... .....Le... . AtIIIIII... 01. '!'Wob1JpdMs • ..U •• "." ............ I ......". Sf GJ. . 7>.. _ ~ __ •• ~H ..................c..c..... ..pIo .......... f# . U... ....-'''~ 9)1 10)1 J IIIII . G.Jfone to ._.G.......(PCA) _......) . ' 112.. i.. . ......__ ~ '''' •• _ __ _ ...... '..... JI'IlIt-.II2 .........."1 .... "'Y"Q'! '8O'M '12 ~NN .. II. <U..-. ... ._.. ...... .......-.._1.L. _ ~......... . 1 12A..L. -....($N.. t)' .. ..JtA.... ......._"".. j ~.' . . . ..... ..... "r "....... lIDnpIIIt ..l1li ""Mtlfr .... '11 ca 1I'lkd .............."'~1!~_1OItII10RKlN 1 1 ... _-'' ~~ .. ...... -it II"II. OJ. .. ... .. 0111..... .... J ..-tD... "· ...... II2. . 12A Ill.. I I 1I...

.._j lIwbwII atItIIwu CGftfJOf ". '\.I. 2e) BUSlNESSADDusS . REGEIVEfl I~ AcIcIreu: C C C/Md:1tw1O..~ 1 A~ ·-~_1 .. .. IDformltloll.. SUI. t StIle: mMedlclna ~: Country: TeJepbaatr L.to .... .... ~ 3.Application BorlII OrkID..fa RMwwfIIlrutI'IuJIIOlU. Y.... dill . ' : '-foIIawina boxes to°Wbte.. B (0) ~~.: (. _0' .. Post Oftke Box...... Iii I~ II I SpecIdIII: 0bItcCrlcI1Ild Gyaecology.dJb ..... C CIId"" 10 .... t•• I! t!Town: - } S&a1e: ..".. M. C o.. lb) HOME ADDRESS 1IriI1IfItJrnI ·OJ ~ CoaDIry.781 . page 4J Lilt Cerdtytq Boird(I) below: Board Name ABMSorAOA ... If. D D C ir ......!lt · . . Llet!'e Me.• lr-~ ub correcdoaI (priIt) 'I' ..D. CAOA) .IIIIIty CertUIatet . page 4o) '..... .. BIle: .. dIIIIt or. Update GearaI below. 5...au • Del.-: i met yoar·z... 3) E-maIl Add.:...... I'IIJIieIan Name: .. please Ileaewa' Du. ° . MA 02446 Pbooe: (617)277-0090 o C/wek"..11 Page 1 of9 .... GIl tmcItWd 11 ~w_. ._ OIteopeWe AaoeIIao..mber: 5) Speeidtiel 617·277~S3S IflllrllCtlons.. . ~E 2) Add ..I:.. Date: O~ ~51'lOCn ..... PuN __ Wow: .. _ .... Jfyou WIDt to c:bIop your CUI"feIU srasus....... aDd ... PART A 1) CUrnnt Statui: ~ ' Massachusetts Physician ~~ne~.....Box ........... .. Plelse CODfttm)'Oar rei orRePtntloJllD MedldDe wttbID Businas 8dd1"llHl CANNOJ' be.".. .. .. a PtIIt Q6fa S.n. ? 4) Fu N..BrookliDe. ': .. 1110 Beacon Street SuiteSb t'o. . 1: e: to... 111 . : CI Do DOt willa eol'lMW . '0 Retiring D'.... CouIdry: ) t:tltIIIOI ". StaIr... ...' ty"owa:.... : tIL.. CertUlcadoa II . J lime TeIepIIoDf: ( . ~ ~: APR"I' ~. C Obslolrks &: Oyoocolosy lY ·i .. i. Pleue Idd CertlflatelSu Obstetrics 8I1d eABMS Ij I .. 4 eoatad reqaired to aotlfy ... Actiw ... .. C 6) Carrellt AmericaD Board ofMedieal Spicfaltles (ABMS) or buIrrII:IlDIII and ReMwae/lf8IrIICdoI&r.. check .....1 I Boar~of RegiStration ~ Ly/T0wa: ~ ..) ·~ ~ I cdve oaly oa.· '.. ts-1tmNQ/ ! LIlt "" . HOMeIllltllwl Ad*ea: a'P()# 0JJ'Ic.. la) MAILING ADDRESS ad:11!:tdaY' of.

.. 2) AdcIraHSA Coatad Informatiu... o: -...D...mJ RllUlWtli llUtntcllons......... below: 4) Po: N...•• U'IMCII • ...? 5) Specialties (Su RmwwaIllUtnlCliOll8..... YM an aid 28) MAILING ADDRESS .tntcti07l6...Baz Home Telephone: ( ....._ 10 S....[ «..... C.... ...... CANNOT bea PoIt 0ftIce Box... to r.... PABTA I) CIIrnat StatuI: !leek Reaewal Due Date: 05l15J2007 BIrdIn. U Address: IIIItbwa ctIIIIIOIN tI Poll ()jJIca Boz !-mal'" Fal N.---... Obstetrics &...ew ...-: Country: ) be II POll 0JIIt:.. page 3.... IhIsIIWI Correct)'Ollr Eo... Massachusetts Physician Renewal Application Active Mo. please cbec:k rail of the foIlowin& boxes to'indJcIte )'OII'_1IItUI: ODI)'0...(priat) Mailing AddreII: City/I'own: Zip: State: Country...... of lay ... pap 4J 'o. dJtmeI dIUtItItIn# Homt IItItl1'a8 BusiDaa~: CGIf1IDI 2e) BUSINESS ADDRESS 1180 BeIcoa SRet Suite5b BrOokline.. : . alld .: lfyou want to change your current status..D Name: Borill OrldD...': • /WItwall".. 1CerdfIeMIoaI CertlfleateJSu.. PJeue add addWo......... of ......-..) Del..t....) Active [] Retiring D 1DBCtil't C Do aut willi...: 5....... Please coaOnn your: add .... ber: 617-277-4535 page 4......... (AOA). _ l~.....'78.. nqalnd. (Sa mcloud InstntClIOlll t. _. .-----PIa.....--------------------... ....... required to notify tile Board ofJtecistratlon In Medidae wltMB 30 da.. DlWltt ......_ to aUr&e tllil fllfldnu 3) Business TelepboDe:LJ..... '. ~ AddIIIouI'Spee~: 0bsIe1ric:s IDd Gynecology C C C 6) C8rreat Americlin Board 'of MecUeal "......ltleI S (ABMS) or A. ......a:pllWc AIIoc~ Lilt Certlfyilll Beard(l) below: BoIIrdNaac ABMSorAOA Update Geaenl CcrtlRc:atll aid belo". Gynecology ABMS Obstetrics and OyaecoIolY D D D D Page 1 of9 ...hlpeelatty SIt.. add ..... MA 02446 Cit¥trown: Zip: StIle: CouDIry: Pbone:(617)277~O [J Ckct. ... M... IJ Clllct "- 10 ~ tit" tII/tIIw$ Home Address: 2b) BOME ADDRESS Citylfown: Zit!: Phone: [J CIIIct..a.

..Ne.. ptIgI S..... wilen. rss.. §a. .RMNQ/ /nstrl4ClioIu.........) a) MIISICbutaUs: 7) D. -- ILIIt ..... MaItII eare r._ til"""" Sl7tl . ReuwGJ /nttnu:tit'ml. Iny •• rpry In your M . M. .. booklet lnet.... II C [J 11)eire of patlea ...~------~----------------...1: (/... to pnetIee o: .. 10) UIt all work litel ia MaaaaebllHttl...mca _ or an work Iita II M... . laducl".... P..... or eo. please complete Fonn PCA~ "Office Based Surgery" Fonn on pep 8..: --_....... an . anbIc homes... clauset:ta oftke? mallMtftnll JlfItnIClitJill. LIeaM Numbers Cor~DI: Massachusetts Physician Renewal Application Pl«w .....dUdII (wilen"...P. race . Cf1IfWdkHu 8) Other. Y. RenewalllUtn1C11011S...._.... won'" _.ac:buetta &IfIIKIve and dacrlpIlolt on page 4.Federal (DBA) XS: -_. I •• : CI o 13) Do you D Not involved with direct or indirett patient cue in ~ A Government Employee under Federal Tort Claims..... en . For the ..ubJect to Board Ipproval (A1ttICh • cow. ia M_uuseUs rs..... .. Page2of9 ..... ella . ollJeet.) 1'\.) 1 wM Active ltatUl but 11m not reqoind ... 1: _..doa o.. Ilaft IUdialbbDItJ .. ~ ~ 4.am... c).. a.. Elizabeth's MediCIl Ctr of Boston .. ~ $..-----------_'..... Qw... --aU...... ..... 18 of die Reuwallastruetlo.) Chmweto: _ CharJp to: _ Infwt Averqe weekly hours involved in: a) inpatient care b) outpatient care ~ hrsIwk hnIwk brsIwk 12) MedlCll IJabldty IasaraDce I_formation Clleek ODe...) il Locum tenens must list policy dates..· _ perto... [] No IfXa.... _ . of tile IteaItIl care ~ refer to .. (CIc)r or TowIl) ~ .. LIaMe..-- were ..~~'l" p:ovfded dIrouaIt: _ [J I_faace Carrier (<<NIIpI" below) Current JQIW'IIlCe PoJicydates: Type of Policy: camer: • Cban&e to: From WJllJlODl' (EIltJose Claims made with tail coverage [J Oc:cunence Polley I eopy olthe eertlfieate of lasuraaee or tH tlleelllett) o Letter of Credit D I .. Drovide ." ..lr g' .. 1d).....ld Un.... wilen JOlt NJ b)Federal(DEA): . DNaJae: BorIII OrkIn.. 9) Smt.} Beth Inti Deaconess Medical Center 811" .U lafona.... etc. aD • I...... My medica1lilbility Insurmce CRICO T.... TUIt .. poge 4.. C C Newton·Wellesley Hospital Sf._. -• .D.de IlIIDItIHI wItII ~ . Act(FTCA) Otherwise exempt (please "fJlain).1...

e. ..... b) PENDING: Are there lIlY mvesolved malpractice claims aptut you todaY.~ be •• bad~ (check one) [] . JHIP 8. duriIII. flied . Page 3 of9 . a. M_.. or his 8DYmedical malpractice claim been made against you darl ."~ You must check either YES or NO to each question. th. settled or adjudicated any lawsuits. or orofesslonal assocfation? 19) Have your privDeges to possess.. medicallIIIIpnctice claims.-cIed. [] c) (fyou are exempt from CME requirements..._. pup )nCIk:e. L_~_. ...professiona1 conduct in the practice of medicine.. ProvIde details on &mlA If you IDIMf"YSS" RedewalInsb'uctions for addftional infonnation and definitions.rp or co-pa..21.hrae "tlme period" refen to the foIIowl . denied. limited.. Uceue ReaenI AppHatioD to the day you IlK.ll'BDCe c:oYa'88C in ~ to In inquiry by a mcdicalliabiHty insumnce canier? fi'y.. __ .. arouJ) practice _. a) New: Haw there been any claims... ' .. . this time period? c) Are 1here any aiminll charges pending agaiDst you today? d) Are any Applic:etioas for Issuance of Process pendiaa apinst you? II) INVESTIGATIONS AND DISCIPLINARY ACI'IONS a) Have you wiIbcIrawn an application to any~llU1horfty. other . tIIH period? (110 above). appIic8don to become ...: Have you resolved. J.. terminated.waJ JPIItnICIIOftI. this time period? CHARGES 17) CRIMINAL a) Have you been cbarpd with lIlY criminal offense during this time period? b) Haw any criminal offeo$eslcharges against you been resolved durin.. 14) CLAIMS MADE 'JOI!rlilt ~.. JlVUP practice. cbiaa this time period? b) Raolwd.) NEW: Have you received notification of a claim. the . impased a sun:J. CME EXEMPTION: Inactive Status tta a.) Refer to YD NO ~! ~: %: ~: ~ to In)' qtIIItions.._: day you Ia qaestJou 1. allowed 'license or have you been denied a medkallic:ense for any reason? . u... claiml_ haw not been finally settled or finally adjudicated? 15) CLAIMS CLOSED Has any medical nudpractice claim against you (whether or not a lawsuit resolved.._N__e:_BorIs 1 O_rld. dispense or presaibe controlled subitInceI been . . you. wheda' or riot alawlait WII flied Oft dill claim... bedh care faciHty. obIo_ %1) Ha$ lIlY medk:alliability insurance carrier restricted. or surrendered to any state orfederllllencY1 2t) Have you withdrawn an application for a meciicallicense. .e. check reacm for exempdoo.. or placed lIlY c:ondition related to professional competeney or ccaduct on your ~ or have you voluntarily restricted. i.aU __ ftooIa . this Reaewal Appllcadoa. D No b) Ifno... employer or professional association? d) Have you been the subject of a disciplinlJy action taken by any governmenlal audIOrity..idencyIFIJIowIbip traiaiD&. _I_Ne. group prICtice or empIoyw'J c) Have you been the subject of an invesdgalion by any govemmeotal aUthority. limited Or tennioaled yourins1.• . hcaIdt CIR fecIIity. htal1b en facDi1¥. employer or professional association? b) Have you ever taken a leave of absence from any health cue facility._ _51_70_1______ .yDient. are you requesting a CME waiver? A CME waivei' DYa [J No esphMloll date.D_.... other than medical malpractice claims. or adjudicated during this time period? 1'> OTHER CIVIL LAWSlJlTS WII filed on that cJUn) been Question 16 refers to claims or actions related to your competency to prKdce medicine or yo. restricted by. .u 30 da)'l prior to )'OUr.....reYObd.) request tona .... __ .t ... settled....Massachusetts Physician Renewal Application __ PbytieiI.

10) I certify thlIt I have complied with my obligations related to the withholding IIDCl remillina of c:bDcl support purIUIDt the Patient II) I certify that I have complied with my obligations to file an Incident Report with 6e Bod when 0KIIIin adYene.. t ".a. ptnUIftt to G. 112 sec. sec.JuI tllsftMl(h. As "" tqJJJIlctuItlor NIIftJt1tII 0/11'" ttl pI'fIdIa IMtIIcIM. and I understand my obligations underG. I bI colllhldM for ctIIIPIt:tIM . IS.I have reviewed my Physician Profile and attached a copy of the Profile willi cgrrectipns.. !I or lily BoIrd replation.. . bums IDd GIber iqJuries punUIIIt to G. 62E.L. RC.. 4) I certifY that I have compUed with my obligations to report the sec. ojperjlll')'... 6) I certify that I have compiled with my obligations to report a physlCian to the Board of MediciDe. board II. tie Crlllllnlll History SystellU BOIlrd Ollly I11III llilt It tt1IlI ". S) I certify that I b8\1e.-. 5 and the Patient Care AssesIment . 12M. 112. firm or GIber legal entity to wbich I have refened a patient for physJea1 dterIpy services pw1UIIIl to O.._ to repon abuse or nealec:t of disabled pul'IIIIlt to G.." bt/tII'IIfIdIolljro". SF. 11BIdentad dJM on Assessment (PCA) programs at the health care f&cUities where I prlCdce report cenain ..-. No. 2. _tllMII6f.. 49A. that. 12A ]12.... (Sa RMIIWfIl ~ ~ I have reviewed my Physician Profile at http://profileuD''''D'''dJ'om'mad coaftnn thIt die inftIautionis .YOU MUST UTAIN A COPY OF YOUR APPUCATION FOR YOUR RECORDS.. 2) I certify that I have complied with my obtiptions I !mdersTaDd the punishment for failure to comply. Orkill. petjUl)'. 3) I certify that I have complied with my obligations to report abuse. Ill. sec.. Massachusetts Physician Renewal Application Name: Bo . your PbyIiciIn PIofIIe will aIIo be updIted.01' IDciclencs to the BoIrd.. .: 51701 PHYSICIAN PROlILE PARTe PI D ~ o certification lDdIor hospital amllations on your renewal appliclltioa. sec.) CERTIFICATIONS I) I certifY that I ba'le complied with my obligatioos to report abuse or undenIInd the punimmeat for fanll'e to comply... wilen I have a reaIorIable buia to believe that person violated any JXOViaicms ofG. neglect or fInInciaI apJollldon ofelderly . c.. to G~L c. I~ tIC. DCB1ect rL c:biIdJaI"""_ penoIII to G. FOR CUDBNTIALING AND roa OTHER PIJIIPOSES.". e. M.. c... purII8It to GL..L...L. (PIeae nolle that if you cbanpd or corrected your business IddreIs. 112..I2A.and I undentand the punishment for fBilore to comply. dtdms. c... Co Ill.J IIw. 8) I certify that I have complied with my obJiptions to file Massachuetts 1IX retumI ad 10 pey M_IICbuIea:I.19A..D.. sec. .L c. 1 U"'r~ cn.. ".00 . G. 112. sec. cornet../ortIIS tI1Id8tlltellte"ts./NM CII# MAKE A COPY YO APPLICAT N AND ALL ATrACHMINTS MAIIJNG. ofwoundl. tllIIl its ~ batrllClilJns. sec. 1 Ikeliln til".r IWIItNI tqJJIIIctIIIM . 7) IcertifY tbIt Ihave complied with my obligations related to chlrailll and collec:daa fees fhml Medk:Ire beaefIcI.L..1IrGN extIIIIiMd tIII.. Page 5of9 auou . 12) I certi1Y that I have complied with my obligations to disclose myowDersbip inIIerest in Ill)' J*IIIeI1bip.. 3.L..L Co 112.. lIIId to tlte bat 0/111180-.119A... treaUneat .L. 62t.L.. pursuant to G.. )II'ICIb 1pICiaIty.... c. _iDols phoae . tile ""01'lUlltM ~ IN..) . ad I u«deallabd my lketue shall not be issued or renewed UDlessI mike tbeIe certifications under peDIIIMI_ of employees and COIl1I"ICCOn punumd 9) I certify that I have complied with my obligations related to the ~ to G. llceUIU'ft.". u.L.a to ..... c. i.Ph. ewaIs occur in lIlY private office.. 243 C. complied with my obligations to report the tratmcnt of viGCims of npe or saul aRUlt punuant 10 G. corporation.IId colflP/*.IeC.tes in IiCCoIdIrIee with the Medicare fee schedule.. c.M. Co 119.. and I 10. My status is Inactive and I do not have a Physician Profile. 11111I crIMlnlll record deck". 5 I A...L.

. ber to. PIP 21 for more infarmItioD).3Jz.... ' . or makes any false writio& or doeumeat knowina the . for IIINPI direcdy by using the NPPES .: '1"'1 . Date: ..iaIDIe No.blts. you must DOtify the SOlId by ~ 1be NFl form It die Bon's website (see Option 2).C. _ 18 U.. Optjog 5: If your license status is INACTIVE.Massachusetts Physician Renewal Application PhyIIdaa Name: Boris IOrkla. 100 I audtorizes criminal penalties aaainst an individual who in any matter within the jurisdiction of Ill)' cIepIrtment or IpDC)' of tile United States knowinaIY and willfully falsifies..000..... or health orpnlzatioD. red to . $2$0..: .000 and impil. o I have applied My current NPI is: I have personally applied for for mffiCd IlIIQ]~ [~l~ [Ii] party (enter IIld sip dle bottom of the peat.. Supply the Board ofR.... NPI 00 your beIIal£ Social SecurIty Number: State ofBirtb (if US): Gender: COUIluy of Birth (ifOUlside the US): _ IpBtl'Jlltipn 9P th' NatiogI PrpyMtr . aatllorlze D I do JUIla.. lIh plan..thom the Board ofAeptntion .... . 1 D HIio8I: 0Jgi0n I. such IS thole IIIIigned by beIlIb plans. please review the followina int'omIIIIion ed 85 necessary.._y provider taxonomy code is required if you authorize BORJM to apply for III NPI Oft your bebaJf. .. I hereby auchoria As 11\ inactlw physician. You canappl... I.. iRfonD. you may elect not to obtain IIINPI number.. Taxpnomy rs. ~ IUlddate to eo t ...site at www. COIIIIiIIDy f&IJe.S. . NPI on illy bebaif. Please provide the HIP AA taxonomy (specialty) codes (mer to Ra. all individual and orpnization IDINTIlIEB mrll 2.. 3S71(d)alto audlorizes ftnes ofup to twice Ihe gIUII pia derived by !he offender If it Is greater than. Please complete the NPI form It the BoIrd's web site It rmrmr •. fictitious or fraudulent ltItem..euraac.*. SignatUre: Page7of9 • WI AYtltortptlop for NEI g. Individual offeoders are SlJbject to fines of up .J: The NPI will replace all other identifiers assigned to health care providers. .dOnon tltls form II tnt aad ... In MedIdIIe tepl'O\'lde .egistration in Medicine with your valid NPI......_ Qgtion 3: CertifY another audaorized institution hIS applied for an NPI on your behalfandyou "ve nat ItJCIIwd h )'II (supply inIdtution's 1IImO).s. I..oMdIIlI for lIP to the yars. I do not wish to obtain 8Jl NPJ. the amount specifically authori2ed by the MDtalcma statute. youmust notifY the Board.: ~ . PeyItles for F. bpa. Under the final H[PAA HPI Rule. the IppOpriare box belowt supply appropriate In~ III NPI.. Once you have received your HPI Number.NPPES. order for your lleeueto be mewed you must take o... 18 U .11. thorlzed bospltal. please indicate your specialty in tile space provided (TIxaDomy Deaiption). Qptjon 4.. NPlby Mly Zl.. HlPAATAXQNOMY CODES an NPI using a third name): -_------ the Board to apply for III.. scbIme or device allllterlll feet. (follow iMIrucdons b Opdoa 3) (You must provide your NPI number to die Boud when receiw:cI.. M. . Inlddition to providing lite 1IXonomy code. fidIIe.tewalIUIl1lcticms..cms."....a/J 0 .pI. .. Please note: This infonnation is regujred if you authorize BORIM to 1PP1yfbr ....t 01 the 10. NPI . fictitious or fraudulent stIIement or entry. .1IIMd ~.acialtv> Code Primary Provider Taxonomy: Provider Taxonomy: Provider Taxonomy: (dJ@)~~IeJ~~1QJjJ DODJDDDOCD DDDJDDDDDJ mate correctiods NPI REQUIRED INFOBMA'DON In an OftIOing effort to improve the quality of the information we collect.cdoa. . 11ae primary purpose ofllle NPJ is to uniquely identify health care providers IS "heabh care providen"ia HlPAA stmdIrd aaw... 2M7. The prIn..aovQptjm 2: CertifY you have pcrsoaally applied for your NPI and you have not received It yet ODce·)'OU have rteeIwcl )'OW' NPI NIIIIIbIr... Audlorlze the Board of Reaislrltion in Medicine to apply for an NPI on your behalf.1: c:ovmd providers will be .. D Male D Female Clw:k .. 0tI'enders that are orpnizations are subject to fanes ofup to $500.IsfMn.. conceals or coven up by any irick. _.) o By chedWts this option and signing the bottom of this page..: and health care purchuers for purposes of conducting these business transactions. NATIONAL PRQYIDIB t....C...D.ernb or representations.._. or ..

.........eIlO iIdicaIe)'Wl' .....c·AMIIeIIaI s. 5) 617-277~53S - N.. ". APR 22 2009 f ZIt: Home:Tc..... .. MA SuileSh s_ f..... (AOA) r.f46 Phoae: (617)277-0090 o Chd'_' "'.urw..J or ~ o.. .: BoliII onm....... a z....PlnleHd .: 5aa1e: CouaIry: ffN.. [J Do IlOl wi61O UIII. nq ....... Y_ .-. aM ..... PART A Massachusetts Physician Renewal Application N. ......... 1) c... req .... Coalry... .. __ o 2) Addrl•••• Cablct brenDadoa... C..... Obelecrics lad G)DIICOIoay D ... 0 C 0 D Page 1 of7 ..... Co_" die BoardofReafJtratloa IDMedJdae wItMa 3t U... I. PIelIe eodna. ~ (Su R_. _"........: 5171' aea.........w.... CANNQT Itt a·ro......... •• C. M...... t... AddnII: IIrIs tJddnll BfUiItaI tIIItJtf# QIJUIOtH d hit QIICf" ~ 3) ..._) aunt« 6t II Po« .r...Ilta (ARMS) ptIge • adOMd IuIrIICtitms tmd R... ~= Cityll'Owa: Zip: B'-'TeIepIIoDe: CouaIry: State: (__) 02.. ad " ...: _ ..low... ~ 3... " - ABMS ObMetric:s IJId Gynecoloay .e....0 6) C~ AIIIerica Board of Medical SpedI.D."..._ .t OIIke·Box............ . DIllIe.Me...... AII . (priat) _ MIiIiDa MdN.....wal hutrucIioJu.t Sbatlll: Active 0"1512009 Jf)'OU want to chaup ~0IIIy-: Ac:dve • p1eue cbec:t all oft8 ~ RaewoJ lIutnIctioIu... ... HtJIM tJiI4rwI 0jJb Box Board of ASGfstraUon In ~edk:l"....: cityfl'owa: Zip: C ad lim '" c:Mtp III&. BoardN_ ObMetrics cl GyaecoJoay ABMSorAOA Ctrdtla - a ~..... _I.... .. Lilt Cti1H)tIII ""'1) Wow: Update GeaenI CerIi&atet . page 4J Delete? [] u.. PIaIe: o Cldhrrlfl~dtI3mUtwr 2e) BIJSlNDS ADDaas 1180 s.........con BrookIiac. 4)'uN.ac.. bo......) MAILING ADDRBSS ...I Due Datt: )"OW' c:um:at ItIlU8."ftWIIlnllructIOlU....r... ofay ..n.. ... sci&e: 211)ROME ADIJRISS Home A"*-: CitylTow...} 0 RctiriDa IDIctiw BIrtIa ...... 1I dIltyC ......r.

... -• ....... ILIlt die ...18 oldie ReaenlIuCractioD booklet . ..••• .... with tail COWDp......ocam 1eDeIII must list policy dates..U lIIf...:U7Il ~ lrt. Massachusetts Physician Renewal Application . .. 1e...... Tawil) Slate .............I . ................ .... ..-.. wurIE HoIipiI..... ActIve . Ja Ma..pd••• tile . pap 5. etc. My medic8l1iebilily Wtn.. ....EIIIII~""""'" ""t}~ C IAUIr efCndlt -Jed to Board D D appnval (AttId • eon... 7) DnlLIctue N....J_J_J_I-9P1 TOJl.l \ ! . dttde...p...... JIIIIe 4. [J No ]fX& pleue complde Form PCA'() "Office Bued SUlFIY" Fonn on . ... prvYidod a-pto: IIIrGuab: _ D Iuiua _ee Carrier feHIPIPoIicydMel: Type Cunat lDIuIaIK:e Canier: CRICO FIOID of Policy: ..nf.ims Act (FTCA) Otherwise exempt (PIf!GSt1 explain)... ) to Hve .. N--= BorIt I 0rIda.. t "I~ 1_: Qwt CX!Cj o NOt involved with direct or iDdiIecIpedeat care ia M_cIaIIeD A Govemmcnt Employee under FedemJ Tart a.' _ 13)De...... S...[J C· II) C..b)outpatieut care 12) M CIIeck ualltllltJlanruce Iafonutfoa ptIge 4J . beaItIa III.. ')80 .....-UJt aD lites .... . cInuettI.aebUlettlltu RDIftWII hrstntctltnrs....c__" I) 0daer . I)~ b)F"'(DEA): c) Federal (DEA) XS: ---- .... .........areal'........ 1IUI'IIIai""'" For of £an" • ......age 2of7 ·..dla& can crl'llItIIIIed). C V. req........ Avenp weekly houri invoIwd in: I) iDpaticnt care .." . doaOll aD work..-. _ .... Ne. (wilen .. c:onw:dou tB .... iacJ... wi........ PIeue·· .ttnIctiDJu.... PI_ ..... tat InIt I . 18) work M .... .....) D I . patleD.oy aIIIIIatieID .. PIII.....) 8............. ... • ~O~TDrJ NewtoD-WeIIeIIey • [J C . ...... cIIIIIa..) l.... (EadoH .1tttI 1'- dacrlpIIoII on fNII' 4) Beda Inel IleecOI_ MedicIl Center (CItJ . §a Gbow - fill.... NJ -.. uy IUItr)' iD yoar MMlldluetil ofIIft? (Sa: RmftWll hutrwcIiINfI.........!L ~ bnIwIt hnIwk tiki Reftnul /futnIcIioJu. P. 1D Muada..) Correc:tioill: LIe . die . I capy ofdte (fi 0 00c:urNaca Poticy dilate01......._ T.) m..... M....J ~" Claims ...D....

. MA. . ......'A. ............ 1iIIII. iD..y ~ .. ... 1..F IO ' c....... "..2009 AI 0).Id~ be IUltVO .......f8bi1ty Iua. _...ee OeD... ClZ2U 1'IdI_..-rut 1IeIDW ot ..1)112010... W_ dIe .... ot"'N. ....... CIf r......... by ..... ... .... ...rV_.. .... ..InIIId 1IIIk . 051231 ....... .. ~ b) iIf iIdhidDIJ..... .~ .... Nt _.._ oIJVW' _ . 1iINilJ ' __ IIrIWllfl........... .......IMC........ of~ ......1Ir . dl AnUdIIIJ: BIDMC-CRJCO... "NioyPeriDd" tioII • .. '· tbiI~ ..... "'''CIIina• .. 111 ...... ..~ Ridt ... BCIUSL OUIHMD BBIB IIIlAIL DBACCJNESS MEDICAL CBlI"BR......aoJ OIJ01flOO9 ~ 1213Il...CoaftrIIIatiou of Physleiau..... polioy ND 0CMIIp... Idd OI.. ..... .......'.* . __ at. ~. r.. "... _ 1wty ClAII' F QU42. ail...C.......... ~II .. .... . Ir5.I152...... c-..01 '....... d PodIatr'IID ..........1lt1ld ..II ... ... __ _ .....2. 33ORIOC'CT INB AVB IIOS'roN....

.. ReaenI AppIkatioa to tIte day yoalip this RID .. . Other than medical malpractice c:JaimI....m-ce COWI'Ip ill.aroup .R CIVIL LAWSVlTS QuoItiaa 16 Rin to cIUu or actioDI reWed to )"0lIl' compeCeIICy 10 )II'IICIIice . t1B ItMI!wtIIllfIInICtioIu... Provide detIiII on lJIm.... a) Nr:v...ctMI -. tIdI .. u. __ .. SJ "10 ya: NO 14) CLAIMS MADE a) NEW: Haft)'OU ft!Ceived notificadon of..e.. .. __ ) __ 16) OTID... .ticility..1InI: there been any claima.. eME waiver'! A preceding yourrenewal ......ccd any condition related to professiooa] compek:DCy orCOllldacl CIa .M... fIciIity. ~ oc . _.y mocical maJprectice claim apinlt :you (whether or DOt RIIOhed... You JDIIIt check eitber YES or NO to each question. 111M DOt heeD fiDaJJy Ietded or fiDaUy actiudicated'l 15) 61- aAIMS CLOUD 11M -...... 0Ibcr _ JaedicaI. ..) Haw )'OUwidlctmwan applicaticm to ID)' goVCl'DlDelltll authority..... if)'Ull ..Massachusetts Physician Renewal AppliCation ....... revoIred. .. b) PENDING: Ale dun my UDI'eIOlvedDllJptactice clIimI . _CJhwJe tit co-paymeDI. health caR iIICiIily.. aay~ malpractice claim been made agajDst you .I.: ..D.. N-= .. r c) 1f)'OU are exempt fioJb CME rcquiRmcnta.eNe. allowed • &c.... 10 In iaquJry by • medicallilbility iDIunmce canier? 22) a)Have b) IfIlO. c6ssioalJ coaduct ill die pdCtice ofmedicioe. limited...-? - IllJNVaTIGATIONS . claim. ... _.. 01' aurrenderecl to any scate or fedenllFlCY1 baca lUlpelded.pactice OJ' c:mpIo.pication for a medicll license. __ ..•.... J7) " CRIMINAL CHARGES I) Have you bea charaed with Illy criminal offeDse duriDa tbia time period? b) Haw lIlY c:riminaI oft'eDacIIcIaaqca ....%I. CCMII'IIOt 01 bIve )'011 voIuaIriy restricted... c) HaVe you beea the aubject of an investiption by lIlY ~ auIbariIy .._. "_.. tbe pbrue "tiale period" refers to 1M foBowbIa . filed 011 ..... whedaer or DOt........ disciplinary action taken by III)' ~ 1UdIarity.e .... dispenee or prucribe coneroIJed ...... . limited or te:rminated your a.._ JI. aettIcd. IJ 0 Inactive StalQ D lteIicIeDc)1FeI1owIbip II'Iiaina .utt .. ...jatioo') d) Haw you been die subject of. or"'-' _11tIIOCiaticlD? It) line your priviIe&es to poaees....t IHlt30 days ....... ReaewIl ~ for IdditioDll iaformaticm ad definitioas.. you completed )'OUt cME reqWremems are)'Oll requestina.... puup. .... to became or line you been cIa1icd • medicllliccnse for any reuon? dIIa_ 21) Hu IDYmedicalliIbiUcy iusurance carler restricted. )'aU duriIi tbil1ime period? b) ReIoIwd: Have )'OU resolved..1 fa q1IeItiDaIl . em: .. DYa 0 No [] No ACME waIYer reqlltlt form malt be labmfttecl.ionalaaoeiation? b) Haw: )'OIl ewr liken a leave of Ibsence from any healtb care fM:iHly.. tIDpIoya' OJ' prore. cn.. settled or adjudicated lIlY IIwIuits. AppIIatiI& . wv....... reitric:ted by.."ac..tpncdc:e ~. cilia .. CME EXEMmON: Page3of7 (check one) to... 21) Have you widIdrIwa .... ... tilt . lamillllld. deaied. &Ied ...pinst you been RIOlved duriDa Clliltimit period? c) Ale 1bIn III)' crimiDll cbqes penctina apinsc you today? d) ARlItII'J AppIieationa for IIIUIDCC oCProceas pending agaimt you? AND DISCIPLINARYACI'IONS ..... ... chcc:k reMOD for ~CIIIPIiOa. or adjucIicatcd cIuriDa this time period? I a..1fOIIP pdCtice • employer or pro fessiODII ISSOC..B.. "YES" eo ID)' Ida. JaWIUit \VII fDICl CIa .. perW? (_Ibow). or pJ. or)lOaF . 10rIdII....w. __ dda IiJDe Deriod? ...aroap pnctice.

. ". lee..L c..tIM ."t11 cae bt/."". IM (i) Dolo: Ju~_iwf ma O'I'BIRPlJRPOSD.. amliltiOllS OD your renew8l appUcatioa. "lIMed. . &In cr OIlIer IepJ entity to wbicb 1hive referred..: 51.ce......L c. JteauIaIiaaI... 62E.".L.. IIU /rM iII6tIwIlMS...." .. or.Jt ..L...".._ co. ad COIllpiet& A s «n IIppIIcturtlor NIl.. 112...00 the Patiem CIR .. N. myobUptions to report the IIaIIneD1 ofYlctia» or 1eXUII--.-wt 10G. 49A.. aDd ] 1IIIIIe:raad the punishment foe WIare to comply.... ceni&atiaaI rt..L c.. mel I UDcIerstandmy obIiptione tmc1er G..... m..... wbeD (lane • reasouabJe bIsis 10believe that perIOD vioIa1Cd any proviIioDs ofO.. 112." .. r!iI CWk OM.-10 6) I certify tball have camplied with my obliaatioas to report • ~ 10 BoIId ofMecliciDe.""" DI • .L .... to file Maaac dIIt. 5 or.. )'OUr""'_ ProftI..d ...L.... G. 12A1l2.. ~ .""".._ 3) I certify that I hive complied widt myobliptioGa to report .19A.. D ... tIuIt tI crhrIlrud record checlcIJfIlj' be CIJ.Massachusetts Physician Renewal 'Application ... II.. 112 _. 8) I certify 1bat I bave compJiect with my obliptioas per. fioom' Medicare lbeaefidlliel iD a:eouIwce with the Medical"e fee ICbeduIe...llprpfjlcvnepme4bomd'" (PIeue DOte that if you chanpd or corrected your buaiaaf .. 19C. fell' faihn 10 comply... ... wiIi . niaiac of ddId ..... ao.L c.... 15..." lUll.. 1pICWIy.) IiuIuIu& tilt" I IuIN a:IIMbr_ "... J"""'_' to G. W o [J c:c:rtifica1ion boIpi ...rIO the G. to file aD hEicIeaI Repxt widllbI Bon wbea prMIe oft'".. my obtiptjona related 10 Ibe withhoJcfiaI ad .. it.. M. ll~ """''''1$. Sptnu BlNlrtI ill.nc.. 5) I certify Ibat I haw complied with •.. 12A.... YOU MlJITDTAIN COPY OF YOUR APPLICATION FOR YOUR RECORDS..D. G. FOR CItEDBN'nALlNGAND ....e.... 112.~ lUll l1li4 to tIt8 bat 1)/. ...4IIctdfor ~. puIIUIIIt to G.. 1J 9. of......Mr JIMIII*s IJjpuJ-ry. 5 mel che PItieol Care All: J] .... capondoa..... tee..d7~ Page5of7 . SF. aePcc or .. oIe1d1ny.apport)JUl1UlDl1O 11) I c:atify Ibat I lave complied with my obUpdons. 4) I cenif)t 1bat I bhe complied with my obligations 10 report the IrabDeal see.. StA. .juzy. ... ) My ltltus is IDICdYe aDd J do not haw • Ph)'aician Profile.. 62C... 2.. my Hceuae abaI1 not be __ or renewed IIIdlOpay N 1 .."11"". --. _ 7) ] certify 1bat I have coqJlied with my obHgatioas related to c:hqina lad coJIectiDa .L.....ll'A.. 112. PID'SICJAN PROm. e....aadealllad did to tbe .._ pia_eo oIIIer ./tJrwu u..1 PARIe I) I certify that I hive ccmpJied with my obliptiODS to report abate or JJe8Iect of ddkIraa ..__ .: ""'1 0rIda..L c. c.. 12M..jorJ eVIIIII occur ill lIlY I. lie...L c.1eC. G. 112..L c.t1w CriMinlll Risto. ICC. 10.L c......... patient for physiQl tberIpy serviceI paIIIIat to G. til ~ • . Q'a RMftltllIIumtt:IftHu...... A MAD A COPY OF YO~nON AND ALL ATIACBMBNTS:JDOR& MAlUNG.. All.. IIndIt 16 ""._ andenIIDd the puoiahmeat for faihue to comply.. eec. ad I 2) I cerdt)r Ibat I hive c:ompUed willa my obliptiODI to n:port abaIe or neaIect of the pun.1DII11IIIdenIIDCI UDder peMItieI of 9) I cenify that I have complied with my obtiptiODl related to the reportiaa of empIoyas ad CODInIotorI panaIid 10) I certifY Chat J hive complied with to G..Wclsment (PeA) programs It the health care ~ wIleN J pNCtice report ceI1IiD u.... I haw n:vic\ftd my Pbyaician Profile mel attached • copy orllle ProaJc" '_'Imr ptIp ""'01' :rIP ~ CGaIInD _ lilt W illCCIDIe.. .! I bave rniewed my PhyIiciu Profile It hUp.. pII1neIIIdp.ICC. ctm'UI... 243 CoMJl 3. IeC. 112. 12) J certifY IbM I have complied with my obliptiona to dilclole my 0WIIenIhip iaIeIat in ...c.. boIId be .. c. purIUIDC 10 G.. LIe_ Ne. I "".... puIIIIIIIt to G... tUm fro.

. & Contact Information MIIIong Address: HolM Address: lusl .. where you New Jersey ware prevlou.... etc WorkSlta Beth Israel Deaconess Medical Center Location ra.02446 United states of America (617) 277-0090 3) EmaIl Address: 4) Fax Number: (617) 277-4535 6) SpedIIItIes .. 8) Other stat. LlcMseNo. you . prtvate offICe. CUrrent ... including health care facilities (where you are credentialed).. AIIIIBIAOA (AIMS) c. Obstetrics and Gynecology I) CUmlnt American Board.1y licensed ..ae1of5 Dale: "'112011 'I1mI: 1:2t PM . : Active LIc:e. of MMllcai Specialties Informlltlon ..tIftcation or Amerk:an 0stI0pIIIhIc Auocldon (AOA) ABMS Obstetrics & Gynecology Numbers Federal IDEA) Board Name Obstetrics and Gynecology Subspecialty 7) Drug license lIIIIIsSachu ..CommonweaHh of Massachusetts Board of Registration In MedIcIne Physician Renewal Application Physician Name: Boris f Orkin. FedenII(0EA)X8 None Reported now licensed to practice I) ... Add. clinics...: 51701 &xpIratIon Date: 611212011 1) Activity status: Active 2) Add .. M.D. 10)Work" Ust of all work sites in Massachusetts....... nursing homes.. wh..ran: 1180 Beacon street Suite 5b Brookline Massachusetts .

health care facility... or adjudicated during this time period? we. or placed any condition relat8d to professIoMI ~ or COIIducton ~r or have you voluntarily restr1ctad. whether or not a lawaul worried on that claim... a) Have you withdrawn an application to any governmental authority. ear..m care 40 hrslwk Policy start Dat8 01iU112011 care 20 hl"lWlk 12).2ofS . b) Have you ever taken a !eave of a~~ fl"9m any health care facil~. restrIctH.. i. other than medical malpractice claims.. UcMu No. ciJring thIS period? 17) Criminal Charges . or has any medica malpractice claim been made 9inst you durirg WI time period? b) Pending: Are there 8rPf unresolved malpractice claims against you today. 11mItH.... employer or professional association? 11) Have your prlvl~to )"KS8SS. allo\wd .-on? to ·21) Has any rnedlc:alilabilly Insurance cam. ~Follcy 1&)=~:1 14)C.: 0lil912011 11mI: 1:2'1 PII ... den"'..1 . Question 16 refers to claims or actions related to your competency to practice rredicineor your ... rastrIct8d by or sUlTWldered to any state or * 1gency? nces been .. p~ 1213172011 End..... you malpractice claim against you (whether or not a lawsuit resolved. CIvIl Lawsills . filed on that claim) been . group practice. IgIpIIcatIon become obsolete or have you been denied a medical license for any .. setUed or adjudicated any lawsuits. ponse to an Inquiry by a medicaillabilly Insurance cm1er? COY".DIll.D. filed against you during this time period? b) Resolved: Have you reSOlved. . criminal charges pending against you today? . other than medical malpractice claims. a) New: Have received notification of a claim.. health care faCility. Imposed • surctwge or co-payment.Commonwealth of Massachusetts Board of Registration In Medk:Ine Physician Renewal Application Physician Ha... PIg.. 1caI Liablity Insurance Intonnatton CRICO Insurance eam.: 51701 11) Av-. group practice... : Boris I Orkin. professional conduct in the practice of medicine......d .ennlnat... health care facility. gro"" practice employer or professional association? . group' practice or ~r? c) Have you been the subject of an Investigation by any governmental alAhoritY. termlftllld... Have any criminal.. . limited or t... dispense or prescribe controlled rwokecl.e...... settled... offenses/charges against you been resolved during this time period? Are there anv.Idy hours Involved In: ajlnpatlent b) outpatl. of patients In Massachusetts w.. M. 18) ott.. Have you been charged with any criminal offense durlng this period? . employer or professional association? d) Have you been the subject of a disciplinary action taken by any goverrmental alJhor1ty. a) New: Have there been any claims. 1ft al"ry'ApplIcation of Issuance of Process pending against you? 18) Oller Iss .1nsUrInce covwage In . 20) Have you wlthdiawn an application for a IIIIdlcalllcenM. any clain that have not been resolved.. setUed or adjudicated during this time period? .....

.. pi... In an approved R.. In ftsk 40 hours creelN: In category 1 _ hours In 2) for this reneYtillpertoc:l? you ...". ldencyt felloWship proeram..: 411112011 ':fInae: 1:21 PM . answer Yes) ul~ You ~ eo c.. PIa..: 51701 all CME requirements (100 hours of CE of which 10 hours must . for the tlrst trme. . M. renewing your llcen . or your .....Commonwealth of Massachusetts Board of Registration In MedIcine Physician Renewal Application Physician 22) Have ~ Na. LIc:enH No.... : Boris I Orkin.D. 3 015 DIll.

&::tnId~ne? chemical substanca(s) which In any WIly In.:. M..D.our 1IbI11ty1lo prIIdIce .ns. 24) .. 23) Do you have a medical condition that Interfwes In any WIly or 1mb ~~~ .Commonwealth of Massachusetts· Board of Registration In Mlcldne Physician Renewal Application Physician NIImr. Boris I Orkin. u. No.: 51701 .. used any prac will your"lty to Date: utll2011 ""':1:21 PM .HaV:..

.G. n . the above statements and certify that IunderstalMi my . No. ua. 11. I understand and agree to comply with"" obligations to file an Incident Report with the Board when certain adverse events occur in my private office. 9) f understand and agree to comply with"" obligations related to the reporting of the wages d employees and contractors pursuant to M.~ MIl .L c. IIId c:oqMIIe. 119 sec. ull'elnMt to conIpIy with the responsibilities and obIgations of _ell and agree to do so.: UltIZ011 nn.l. c. c.Commonwealth of Massachusetts Board of Registration In MedIcIne Physician Renewal Application Physlc .. 12M.l. accurate. L c.. c.112sec... 62ESec. c. 1) I understand lind agree to comply with my obligations to report abuse or neglect of children PUr5LBnt to M..... 119A . c. . I) 1understand and agree to comply with my obligations to report a 'phy8ici~n to the Board ofM~ne PlXSusntto M. . 49A. ury.re comply..:1:21 l1li . 19C sec.. 19A sec. when I have a reasonable basiS to belIeVe that a person violBted any provisions of M..G.00 at seq. IUId to. corporation.G. 1M. 112 sec. 10 and I understand the punishment for faUure to comply. understand that the Patient Care Assessment (PCA) programs at the heatth care facilities where I practice report certain Major Incidents to the Board. 2. c..G.. I declare that I have examined this . c..I1lahment forfallu". 13)1am aware of my obligations and responsibilities under the Health Il"ISlI'8nce Portability and Accountability Act of 1996 (HIP~nCluding the requirement that I ottain and provide to the Board a National Provider Identifier (NPI) n r. 1 PIG" of! Dat. 7) I understand and agree to comply with IT!f obligations related to ctargil"G and collectilJg fees from Medicare beneficiaries in accordance with the Medicare fee schedule. 112 sec... t .: 51701 Online profile: Compliance with Legal Responslbl . 62C sec. 2. . 12) I understand and agree to comply with m. ptJl'8U8nt o M.L.. 51A and I understand the punishmentforfailuretocoinpry. c. obligations to dlscloee ownel'8hip interest In any partnershiP.L c..... pursuantto-M. 112 sec.ns. and I .L. pursuant to M.L.l.G. 11)1 understand that as an applicant for a license renewal to practice medicine a Criminal record oheck maybe conducted for conviction and pending criminal case information only from the Criminal Hiltoly 5yItem& Board and that it will not necessarily aisquaJify me.G.. 2) I understand and agree to comply with my obligations to report abuse or neglect of dlaabled peraona pursuant to M. .. 5F'.. 3) I understand and agree to comply with my obligations to report abuse.l.G. 112 sec.. 5 or any Board regulation. .. 5 and 243 CUR 3. .. 4) I understand and agree to comply with my obligatione to report the treatment rI wounda buma and other Irluriea pursuant to M... 112 &eO.. accomDInYIna Insti'ucllons.G.. M. D. pursuant to M.. f its o .L c. baR!' mpn~ certI'y Un_ penalties of . : Boris J Orkin. 15 and I understand the puniehmentfor faUIIe to comply. .12A 112 and I understand the pI. neglect or RIWnoiaI explobtion of elderly persons pursuant to M..G. 10)ll.~ hf thi Information contained herein Is true... 'orrrs and statements. 112 sec.. "" license ahall not be issued or renewed unless 1 make this certification under penalties of pe~ury.G..-G. .. to COI'JIpty.L. 8) I understand and have complied with"" obligations to file MasaachlJ88tlil tax retulT'll n to pay Massachusetts taxes and I understand that. to &) I understand and agree to comply with my obligations to report the treatment of victin of rape or sexual assault pursuant to M.L c. firm or other legal entity to which Illave referred a patient for pt1yeica1 theraPf service.. 1m !XI Ihave rev .G.B1derstandand agree to comply with my obligations related to the withholding and remittlrg of child support payments pursuant to M. 12A and I understand the punishment for falll.. III have reviewed my Physician Profile and confirm that the information is accurate.G. 14)1 understand and am in compliance with HIPAA and all other federal and state obfigations ptaoed up:m me as a physician.