‘April 24, 2002 : ‘To Whom it May Concer: 1 am applying for a Vermont State License at this time under my current name, Julia Brock Randall Weston, Iplan to begin practicing medicine in Burlington, Vermont as of August 15, 2002. 1 will be changing my name due to divorce over this summer to Julia Brock. If possible, ‘could you please issue my license under the name Julia Brock? 1 will provide a court order signifying my name change after my final divorce hearing. Burlington, Vermont 05401 (802}- 865-1296Mailing Address: 109 Sie Stet Monge, VT 03609-1105 Tel (90) 828-2673 ax (800) 9285450 tice Lasation (One Prope Sie Montpelier. VF 03602 State of Vermont Board of Medical Practice June 19, 2002 Julia Weston, M.D. 342 Pearl Street Burlington, VT 05408 Dear Dr. Weston: Your opplication for medical licensure appears to be complete. Tt now becomes your responsibility ‘to contact the Board member listed below to orrange for your personal interview: Philip P. Trabulsy, MD 1086 Brae Lech Road Colchester, VT 05446 (802) 893-7624 ‘You must complete your interview within six months from the date of this letter or your application willbe considered sale. This means that you wll have to update the fllowing: Verifications from stotes ever licensed: thre letters of reconmendtion and the Federation Disciplinary report “The full Bord will act upon your request for licensure at their first regularly scheduled Board rneetng, folloving your interview. The Boord of Medical Practice usually meets on the first Wednesdoy of each month Should you have question or concerns, please feel free te contact this office ot (602) 828-2422 sincerely, rie Jen we ar enny M. Audet ‘Administrative AssistantMaing Ades: : Office Location 109 Ste Steet # one Propet Siren Monit VT 03601106 Montpelien VT 08602 Tet 52) 828-2673 Fax (800) 828-5450 eh State of Vermont Board of Medical Practice June 19, 2002 Philip P. Trabulsy, MD 1086 Brae Loch Road Colchester, VT 05446 Dear Dr. Trabilsy: ‘The application for medical licensure for Julia Weston, M.D. is enclosed for your review. The applicant will be calling you to schedule a personal interview. Following the interview, you may present the application at the first regularly scheduled Board meeting ‘Should you have any questions or concerns, please let me know. Sincerely, Thales Jenny M. Audet Administrative Assistant Jima EnclosuresMaing Addie: 109 State Sinee Monipetie, VF US6o9-1106 “Tel (802) 328-2675 avs 02) 928-5450 Office Lacon (One Prosost Stee Montpelier VT 05602 State of Vermont Board of Medical Practice July 9, 2002 Julia Brock, M.D. : 342 Pearle Street Burlington, VT 05401 Re: Vermont Medical Licensure #42-0010441 Dear Doctor Brock Congratulations! On July 3, 2002, by unanimous vote of the Vermont Board of Medical Practice, you were granted a Vermont medical license. Please note your license number indicated above, Your registration card is enclosed and a wall certificate has been ordered and will be sent +o you under separate cover. All medical licenses must be renewed by November 30, 2002, You will receive a notification two months prior to renewal Please let us know if you have any questions or concerns. Sincerely, Khaw Jenny M. Audet ‘Administrative Assistant Queer Please Note: It is your responsibility to notify this office of any change of address. EnclosureMedical Doctor Application Checklist For Office Use Only STATE OF VERMONT - BOARD OF MEDICAL PRACTICE Name of Ap; : ot tg Wetton Address: Oa Fe ar Street Telephone: Oa Wes - 1A Date Application Received: Apri | Ae QOD YLUS Graduate __-Canadian Graduate __taternational Graduate (Cnless noted, copy of original, and English translation if applicable, is required tobe submited). 1) \_ FEE of $400.00 £-tec Za M- J COMPLETED APPLICATION for License to Practice Medicine in Vermont. Photograph (Page 407) Applicants signature required on photograph. ‘Tax & Child Support Statement (Page 7 of 7) Applicant's signature required. Form B: Release Applicant's signature required, *3)/_ BIRTH CERTJFICATE - Notarized Date of Birth: lyin, VT Placeor Binn:_[ ity Od. 6°7 *4) MEDICAL. Spee DIPLOMA - Notarized ri Vermont pad /7_/ 1442 +5) (“MEDICAL EDUCATION CERTIFICATE": Direct Verification *6) MH “MEDICAL LICENSURE CERTIFICATE" - Direct Verification 2) x EXAMINATION SCORES: Direct Verification of Examination Scores: Sf USMLE** FLEX National Boards State Exam + Lambe ofines epic as ken VEMLE ep (cn be oe tn 2 ine\ 2. +8) ua AMERICAN SPECIALTY BOARD CERTIFICATE, if applicable - Notarized bsttines 2G los. N6BC Taternal verification of ABMS certificate using tll free number of ABMS Web Site *9) 9L POSTGRADUATE TRAINING fiom ax ACGME spose siden roar - Dirt Verification, “VERIFICATION OF POSTGRADUATE MEDICAL EDUCATION" must be completed by Program Director. FAH pares 1498 AOOA _ scowe_ a: DATES AcoMe é DATES, ___aceme 10) _J\Three (3) COMPLETED REFERENCE FORMS mailed directly to the Board by the Chief of Service and two other active physician staff members at the hospital where the ‘applicant has a current or recent appointment. Program Director should be substituted for Chief of Service for applicants who are applying for license while still in residency training or have completed a residency within the last year $e ee Sisiiiisertstsiertiaiil or NI rogram Dito Mae we ch huge sa mb Chens i [42 Active Physica Stat Mabe gM )én #3 Active Physician Staff Member nine (ess a d_ 11) > ‘American Medical Association Profile Form. 12) NA’ ECEMG Certificate International Graduate, 1) "A. National practitioners Data Bank sel-query: Applicant sends the original, unaltered response to the Board, 15)_\\ FEDERATION CHECK: Performed by internal Federation Disciplinary check by computer. *.NOTE: FCVS Acceptance - The Board accepts certain documents noted by asterisks (*) above. SIMEDFORMSMDCHEKL WP.[STATE OF VERMONT - BOARD OF MEDICAL PRACTICE 409 STATE STREET MONTPELIER, VERMONT 05609-1105 (602) 626-2673 [APPLICATION FOR LICENSE TO PRACTICE MEDICINE IN VERMONT PHYSICIAN - MEDICAL DOCTOR - PAGE ONE OF SEVEN. FEE: Enclose a check in the amount of $400. made payable to the Vermont Board of Me Practice, Important: on Please print legibly or type your answers. Answer all questions (ront and back of each page) completely its not adequate to state thatthe ‘Board alroagy nas the information. Use the enclosed Form A o provide explanations to "yes" ‘answers n Section Il ‘© Incompete applications wil be returned. © When space provided i insufficient attach adtonal shoots © Alldocuments must be received within sic (6) months or the appication becomes stale and new “documents must be submited Make a copy of bis form and al atachments for your own records. Carefully complete the application a false statements are grounds for unprotessicha conduct 7 © Thankyou for your cooperation. SECTION! APR 2&8 2002 Name_ WESTON vir BRock RANDALL Tes rst ‘Wey rarer Mailing Address: 2 PEARL STREET SEES Ce ee EEC CECE Cee Pu tLin Gio VERMONT _OCYO) _402- GUS: 1296 or ‘Saie) ‘Zip Casey Prone) oftce address: | So Prowect Seer Serena Pe eee lens vr 0540 ox gu? oo cy) Cay ‘Zip Coe) TProney Home Address: Shove _ as boov'e Cy, State:2p Code: Dayne Telephone number Wea Cote: OX) BUF - 49 Br Date of ith: Month;_1 © Day_22- Yer [G64 _ reset ores Bauingdon UT. __STATE OF VERMONT - BOARD OF MEDICAL PRACTICE ‘APPLICATION FOR LICENSURE - PHYSICIAN - MEDICAL DOCTOR, PAGE TWO OF SEVEN. SPECIALTY Specaty: Observes aud Guyccoloci Subspecialty ee ‘American Specialy Board Certied? __Yes _X”_No it yes, enclose a Notarized copy of Board Certificate. Speciaty: ‘Year Contes? ‘Subspeciaty Certheate? Year Centines? NAME FOR CERTIFICATE - NAME CHANGES - OTHER NAMES LICENSED Name as shou appear on your ents coteat:__ Italie Brocke av you evra charge yore? XL You no E PYienitec ates oy Sans nS NS ange He plese See atthe Ket ‘Other Name(s). any, under which you were licensed elsewhere: PREMEDICAL EDUCATION Wesieyean aisererhy Sfax-_b/ea, bachelor of as 1s busoes ‘Name and oeatonofintuton (Frente) Besree) ive 4 Vermmt iqq2- 1948 {Wane and eaten o aston) Frome) ‘Deaeey ‘Wane and icaion a nssabon) Promo) —begigey- MEDICAL EDUCATION-See also Cerificate of Medical Education Vuiversn Vern 14au-1498 na dD ‘Name andiccattn Fists Fronrray Beare} ‘Rae and ocaton fins) Frentfay p36 ————— (Wesree) (Name andiocaton of nstaaior) Frama) — Weare) aSTATE OF VERMONT - BOARD OF MEDICAL PRACTICE APPLICATION FOR LICENSURE - PHYSICIAN - MEDICAL DOCTOR. PAGE THREE OF SEVEN TRAINING. [a Ghronolosicaly residency or other postgraduate taining, Give names, addresses of hospital, exact dates (month, Gay, yean. and type ef taining. Incuce COPIES OF CeRTIFICATES Name Address FromiTo Training Eletlyy Alea Hosy hl Coichesey Avie 1999-2092 i int i PRACTICE Dryounaverosptapriieges? ves _X no have Mppiiccl Ustait hospitals where you have, or previously have ha, staf prileges. include name, adress and dates Name ‘Address FromiTo Speciaty’Subspeciaty sire eee eee ete eee eee ee eee tee eee a OTHER LICENSES Have you ever iéid a Vermont Limited Temporary License? _X Yes __No ItYes, License Number oyou hold, er have you ever held, = medical ixense in any other state? __Yes _¥"_No tyes, complete the ‘Section below and send a Certificate of Medical License to each state State License Number Date issued Status (Active or Inactive) TT ObO0- 000246) 22/1998 achive. Unrited tenrporaty Uigeu se EXAMINATIONS USMLE OR FLEX EXAMINATION: ‘Have you ever taken the USMLE or FLEX examination? _K Yes ___No ifyes, have a CERTIFIED COPY of Our results forwarded to this office by the Federaton of State Medical Boards (ses enclose car), NATIONAL BOARDS: Have you ever taken the Natons! Boards? _Yes _XX_ No ifyes, have a CERTIFIED ‘COPY of your results forwardes to this ofce bythe National Board 6f Medical Examnners (see encloses card) STATE EXAMINATION: Have you ever taken a State Metical Board Examination?” Yes YL _No tyes, ‘make sure that the scores are included on the Cersfcate of Medical Licensure to be Sento thal Goan (see, ‘enclosed Certificate of Medical censure).STATE OF VERMONT - BOARD OF MEDICAL PRACTICE ‘APPLICATION FOR LICENSURE - PHYSICIAN - MEDICAL DOCTOR, PAGE FOUR OF SEVEN INTERVIEW {in which part of Vermont would you prefer tobe inerviewed? (Norther: Butington: Souther: Springfield or Rutend: Centra Nonseten Noy Theyin (Brerdirg fers ) ‘When are you scheduled to begin work in Vermont?_AY) Us. f 26p2_ \Wmat has been your physica resizence (City, State in the past ten years? Waltham Verment — Novth Fen wi Sre_vermun Pre diag ors VerMacy f 7 INTERNATIONAL MEDICAL GRADUATES ECFMG Standard Certificate Number, Date Issuec: Direct Vericaton of your ECFMG CERTIFICATE must accompany this aplication, (See enclosed request form) ‘Are you 2 graduate ofa fith pathway program? _Yes —_No yes, direct vericaton of your fith pathway cericate must accompany His appkcaton. SECTION| PROVIDE A PHOTOGRAPH: Attach a photograph taken within te ist 60 days (head and shoulders). Proofs not acceptable. Sign the front of the photograph.STATE OF VERMONT - BOARD OF MEDICAL PRACTIC: APPLICATION FOR LICENSURE - PHYSICIAN - MEDICAL DOCTOR, PAGE FIVE OF SEVEN SECTION I SECTION Il-“Yes" anéwars to Questions 1 -24 requires an explanation on the enclosed Form A. 1 2 10, 1, 2, 13, 15, 16, eve you ever apped for anc been dried afoense to pracce medicine oan ealing art? Yes _K no "ave you ever windrwn an application fra icense to pracice medicine or any Healing a? Yes_2< No —Yes_ No Tour owed, ae you the subject of an vestgaton by any oir icersng board a. he date of te application? Yer xe Ne Mecca Sree rated 28 = responitie party of 3 confmed quatty concer (quality of hospital care provided to Mecicare patents) by ne Peer Review Organdzaton (PRO) in Vermont orelecare oe ‘yes X No whe lame alractce claim been made against you inthe last tn yeas (wheter not a lawsuit was ein laton to te claimicomplainidemand for damages)? vee XN ave you ever been med down for coverage by a malpractice insurance carer? Yes_X No craurenderca by; Possess, dispense or prescribe contoled substances ever been suspended, evoked, denie,resticted 0 Sutendered by any jurisdiction or federal agency at any tines Sono Ui eas ene @ defendertn any cima proceeding other han anor tac olenses (Note: OW - Ding Wie Intoxicated -is NOT a minor offense)? ‘Yes_X No ‘Te your knowledge, are you the subject ofan investigation for @exminal act? Yes K No[STATE OF VERMONT - BOARD OF MEDICAL PRACTICE APPLICATION FOR LICENSURE - PHYSICIAN - MEDICAL DOCTOR, PAGE SIX OF SEVEN ‘SECTION ill CONTINUED - “Yes” answers to Questions 17 -24 requires an explanation on the enclosed Form A. For purposes of Questions 17.24, the following phrases or words are defined below: “Ability to practice medicine” isto be conseved to include a of the follwing 1. The cognitive capacty to make appropiate cinical diagnoses and exercise reasoned medical judgments, and'toleam ane Keep abreast of medica! developments: and 2. The ability o communicate those judorbents and medical information to patets and other heath care provicers, with or without the use of ads or devices, such as voice amplifies; and 3. _The physical capability to perform medical tasks such as physical examination and surgical procedures, with or witout the use of ads or devices, suchas comectve lenses or hearing aids. “Medical condition” includes phsiological, mental or psychological condtons or disorders, such a but nat imited to orthopedic, ‘sual, speech, end hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heat ésease, sdabetes, menial retardation, emotional or mental liness. speci leaming dieabiies, HIV disease, tuberculosis, drug adicion, and alcohols “Chemical substances” i to be construed to incude alcohol, drugs, or medications, including those taken pursuant to 2 vad Prescription for legitimate medical purposes and in accordance withthe prescribe’ drecton, as well as those used ileal “Currently” does not mean onthe day of, or even inthe weeks or months preceding the completion ofthis application. Rather, ‘means recenty enough so tha the use of drugs may have an ongoing impact on one's funetionng as alicensee, or within the past ive ©) years. “llega use of controlled substances” means the use of contoled substances obtained legally as well as the use of controled ‘substances which are not obtained pursuant toa valid presciiption or not taken in accordance wi the Gretions of a icensed heath Care practioner. safety? Hf"yes,” please exian. 18. Does your use of chemical substance(s) in any way impair or it your ability to practice medicine: 0 and safety? tf*yes," please emia, 19, free lmatons or mpsmers cased by your medal conan reauce't ener Deeuze you receive ergng Saranliaeraeeintesemedsettastriieraneeatebontea 20. Are the kmitations or impairments caused by your medical ondtion reduced or ameliorates ‘he seting or te manner in which you have chosen to prasie? "yes please explain, 1. ay Tepe aren nei te nyt eg aaa 21. Haveyou ever ben donates having ohare you ever ben rated or oh, xii gaye? pees exaan gatesidoo tare wh he SLE vem Wa Ee Bw aosaer |* U i ean es, Tae sr error wren wore i tag Ean Heat sae tnei nee BUi Geo ata aed eat mea ahThe College a Merdicine 0 o dhntoersity uF Beran, : Teall le wher these presently may come, sendelh greetings Whereas the Faculty L lhe College and the Hie Cligeeg Universiby Senate Gulia Brock Randall Weston, B.A. ay he completed the Htudiss. assigned and passed the Examinations We the Spasteer of the Universiby buy rintae if the authority vested jv us de hercloy confor upon har the Dagree of Borhor of Medicive and. admit ter bo all the righls, privileges and honors: afsperlaining herelo | In Weiness Whereef, the seal of the University and the signalare p the Ppevident the Dean and the Jecrcary are hereunto officed. Gero at Bankengton, Vevmont om tha soronteanth day of May in the yon of an Lond, One Fhonsand. Nine Hecndoed and Neely Eight and of the University the Toe Hendaed and Seventh { ob pes 3008 - aww, Cpe PUG XM Rdioga “tives Xa A U‘STATE OF VERMONT, BOARD OF MEDICAL PRACTICE 109 STATE STREET MONTPELIER, VERMONT 05609-1106 (802) 828-2673, CERTIFICATE OF MEDICAL EDUCATION - Tobe completed by an officer of your School of Medicine APR ~ 9 2002 Inereby centty nate Byok Lorde (| Westar was admitesto we ‘(Name) University of Vermont : ica in_Burlington, vr on 0/36/94 ‘(Giy and State) (Date) ‘and completed all requirements for graduation on_ 4/30/98 (ate) AMD. . was granted on 9/27/98 (Specify cariicate/ciplomaldegres) (Datey (AFFIX SEAL) Date:_04/08/02 Signed: (Authorized fhe School) Marg sufay Sproul, M.D. Associate Dean for Student affairs.United States Medical Licensing Examination™ (USMLE") Certified Transcript of Scores US:‘MLE ‘Medical TLeensing Eiaminaion Vermont Board of Medical Practice ATTN: Gloria Hurd; Exee Director Wp Site Sto es . . © Ss Monipelite, VT 05609-1106 = = Examines USMLE 1D or 40/02/1967 AI{Names): » Weston, Julia Randall ve bewrporied t date Test Pass! ‘Three Digit Two-Digit Date __ Fall Score (Passing) __ Score (Passing) @ONS8T PASS 224 (176) eS) ‘Test. Pass! ‘Three-Digit’ Two-Digit Date Fail Score (Passing) __Score__(Passing) 25/1998 PASS 206 (170) 8 co) ‘sTePs ‘Test. Pass! Three-Digit Two-Digit State Board Date? Score (Passing) Score (Passing) VERMONT. —SvIIlL999 PASS 213 a7) 85S) ‘A search ofthe Board Action Data Bank of the Federation of State Medical Boards (FSMB) reveals no reported information on the above-named examinee 7 . Smo) aseists Touchesisi fw Ftc Ma ses ees Ae eG eM oe ee a bent: Tou, os applied tothe face ofthe document, the | UNOFFICIAL COPY, NOT/AN ORIGINAL DO Lets one oe . ceils eae 2 ae seit ace ‘ofthis document bromine scros the face ofthe entire document INTERPRETATION OF SCORES USMLE transcripts include a complete score history and notations of any examinations for wich the examinee sat and no Scores were reported, such az “Incomplete” or “Indeterminate.” ‘Scores ae reported on two different seals. For each Step, the ‘mean and standard deviation of scores onthe three-digit scale for the original anchor group of first-time examinees from medical schools in the United States was 200 and 20, respectively, Most, Scores fill between 145 and 260, An equivalent value score an 2 two-digit sale is also provided. A Score of75 on the two-digit Seale is the recommended minimum passing score. The recomended minimum passing score on each scale is shown on the font of the transcript next tothe examinee's score foreach ‘examination administration. The level of proficiency required 10 Imeet the recommended minimum passing level foreach USMLE. ‘Step is reviewed periodically and is subject to change Factors which influence an examinee’s score include the cexaminee’s general understanding of the subject mater being tested and the specific set of test items used. for an administration, The Standard Error of Measurement (SEM) provides an index of the variation in scores that would be Expected to occur if an examinee were tested repeatedly using different sets of items covering similar content, The SEM fora UUSMLE score ie usualy i the range oft 8 score points onthe three-digit sale and Ito 2 score points on the two-digit eae. ANNOTATIONS APPEARING UNDER "COMMENTS" Circumstances in connection with an administration shown on this transcript may result in one of more annotations listed next to the score. A description of each "Comment" is provided below. Indeterminate - Results that cannot be certified as representing, 8 valid measure ofthe examinee's knowledge or competence as sampled by the examination, Decisions to classify results a5, indeterminate may be made on the bass of factors that include, butare not limited to, unexplained inconsistency of performance within the examination or between administrations ofthe same Step. Noscore is reported. Information regarding te nature of the indeterminate score and the determination ofthe Commitee fon Score Validity is available. If such information is not ‘enclosed with this tanseip, it may be cbtained by contacting the ‘organization from whieh you received the transcript oF the USMLE Secretariat, 3750 Market Steet, Philadelphia, PA 19104, telephone (215) 590-9700, 01 Incomplete - The examinee sat for some, but not all, ofthe Scheduled examination. No seore is reported. Irregular Behavior - The Committee on Iregular Behavior Heensure in Vermont Fie of Pri 7 signee:__/ ‘L/ owe___ 1/9/02 f f.REFERENCE FORM #2: SEND TWO PAGESReference Form #2 STATE OF VERMONT - BOARD OF MEDICAL PRACTICE. Retum Directy te Board 109 STATE STREET MONTPELIER, VERMONT 05609-1105 : (802) 528.2673 APR 24 2002 REFERENCE FORM TO BE COMPLETED BY AN ACTIVE PHYSICIAN STAFF MEMBER ‘AT THE HOSPITAL WHERE YOU HAVE A CURRENT OR RECENT APPOINTMENT, PAGE OnE OF TWO Name of Applicant: JULIA B ta. ASI nd Ihe gpolcants curetcnical competence, ebical character, and aby to work cooperative witches ns "egard please complete the folowing reference form. Thank you for your coopercton, Please compete al pars ofthis form. f more room is needed, please attach addtional information Pada Be Westin wast Flcteber Mller Hosgihl from. 6 ae to, éloz During that time, he/she was (List status inthe tnstuton}: it in Obseterer card SAEORTANT NOTE: I'you ate the spalicant poor or ai” 2 particular category, please elaborate on this spect ofthe reference in as much detail as possible. Bac mesa i oor rai sverpe _/_ Above Average Professional judgment: Poor Fair Average. v Above Average ‘Sense of responsibilty: Poor Fair Average Y pbove, Average Moral characte : y cbicalcongace Poor rat sveaoe poo nverae Competence and skit __ Poor Fair ‘average _V above Average Cooperavenes, Sy won wih others: Poor Fair Average | ._V Above Average: History & physical exam. / ‘ange Poor Fair avenge Above Average ‘Record keeping Poor Fair Average _V’ Above Average Case presertons: Por — Fe ave 7 store Avroge Patent management: _Poer Fair ‘Average above Averagé Prin Patent reasonchi er rai swerce __poove average Competence in being able communicate in reading. writing anc apeaing be Ena J ioe: eee rar __ vege. paove average Paricpaton / Medical Stat Aare Poot Faic Average Above AverageReference Form #2 STATE OF VERMONT - BOARD OF MEDICAL PRACTICE Continued 108 STATE STREET MONTPELIER, VERMONT 05609-1106 (202) 828-2673 REFERENCE FORM TO BE COMPLETED BY AN ACTIVE PHYSICIAN STAFF MEMBER ‘AT THE HOSPITAL WHERE YOU HAVE A CURRENT OR RECENT APPOINTMENT, PAGE TWO OF TWO Name of Applicant: _JUUA BROLIC. DA LL WESTON ‘Tote best of your knowledge, doesidid the applicant carry act the duties and responsibilies ofthe postion at your ‘tution ina Satisfactory manner? 2 Yes ___No Do you know of any emotional disturbance, mental iiness, organic lines, alcohol or drug problem, which might impair the applicants abity to pracice medicine? 7 Yes 7 Ne Do you know of any pending professional misconduct proceedings of matical malpractice ams? Yes/No Do you know ithe applicant has been a defendant in any erminal proceeding other than Iinor trafic offenses? (Note: DWI (Driving While Intoxicated} not minor) Yes Vo Do you know of any suspension, restriction or termination of raining or professional Dleges for reasons related to mental or physical impairment, incompetence, misconduct ormalpractice? ——Yes_V/ No Do you know of any resignation or withdrawal from taining or of professional privileges tp avoid impositon of dscipinary measures? No De you know of any confirmed quality problem (qualty of hospital care provided ‘0 Medicare patents) bythe Peer Review Organization (PRO) in Verret or / souhore? yes Wo Do you know of a faiure of te appicant to complete @ residency traning Yes_y_No programs)? Does the aplicant cll upon consists when needed? Yves __wo In aditon tothe information provided onthe previous page,please use the space below and the reverse sido for {eaboraon onthe above and any edional ormaton yu have avaiable wai the Board nevalusing ie pplcant Of particular value lous in evaluating any candidate are comments regarding hisier notable rencthe ‘ator weaknesses, We would appreciate sun comment ffom you. Any addtonaliormaton shouldbe atathed histor De, Waster i an teetnt Miedint She wit yp) Chord “The gbove por is based on Lane att Hop Sesame eentg eg Sener mprecsen ‘compost a fait vations Cte Soe | futhescertty that tthe time of completion ofthe above training, oF during my association with the physician, helshe was competent to practice medicine and he/she was not the subject of any cscplnay actor. recommend SUL iA Bhovk LAR OPH. WESTOW toricensutein Vermont Tame of Pryican signes:_ Chiserg, ng Date: _£/25/0> PintorType Name an Te: (Yetuune Wl Mp; Abs: then et Uawanty of oom? sale ‘Alegs ‘ auite Revcecy tgam Dual of apt #Reference Form #3, STATE OF VERMONT - BOARD OF MEDICAL PRACTICE Return Directly to Board 109 STATE STREET MONTPELIER, VERMONT 05609-1106 (02) 628-2673, REFERENCE FORM TO BE COMPLETED BY AN ACTIVE PHYSICIAN STAFF MEMBER AT THE HOSPITAL WHERE YOU HAVE A CURRENT OR RECENT APPOINTMENT, PAGE ONE OF TWO Name of Applicant. usin Bree Rasaees hese ‘The physician named above has applied tothe Vermont Board of Medical Pracive fora license to practice medicine in Vermont. The appicant has lsted your name as one who has requisite knowledge through recent obsonetn or the apolcants current cinical competence, eical character, and abilty to work cooperatively with ners, in this ‘gard, please complete the following reference form. Thank you fer your coopersaon Please complete ali parts ofthis form. tf more fom is needed, please attach addtional information. A : Dr S ep ae was at. ton fig I fn 2002 dwrgarine,r (Us statis inthe nsttton: SE IMPORTANT NOTE: Ifyou rte the applicant ‘poor or “ai in a particular category, please elaborate on this aspect ofthe reference in as much deta as possible. owiage Por fae hverage__ stove average Proessionaludgment: Poor _Far_—_'nverage_ Above Average Sense ofresponsiity: _ Poor _Fer “Average __Above Average Morai characteri_ ae tical conduct Por Far _LRverage_ nove average Competence and skit: —_ Poor __ Fair _Letfenge "seve veces Cooperaiveness, - ee ee er HR raaeteEC cL EEC EE Recor keeping Poor Fat _“ingrage_ above verge ose presentations: Por Far “agape _ Above Average Patertmaragement —_Peor_Far—_““hverage_ Above Average Pnysician-Patient a reason Por rar _rverage___avove average Coron igo communicate reading, wring ae pce ae nveage, Xp averse Partioaton in Mosicsl Stat Afairs Poor Fair Above Average:REFERENCE FORM #3: SEND TWO PAGESGaterence Form #3 STATE OF VERMONT - BOARD OF MEDICAL PRACTICE PR. Continued 409 STATE STREET * ae MONTPELIER, VERMONT 05608-1108 (202) 820.2673, Name otappicant, tuhn Crk Rewclall bhegbon amen nt Your knowledge, dsl he appicant cary ou he cies end respons ofthe poston et your insbuution na satisfactory manner? szYes "No ad =~ mae htm of any enasonaldsturbance, menial iness orotic ines, slehol o: uy problem, which matt ‘impair the appicants abit to practice meshone? Yes No 2eZey knew of any pending professional misconduct proceedings or media! malprcice sims? i Yes _SKo a You know f the applicant has been a defendantin any criminal proceeding ther han ‘nor wate ofenses? (Note: OW (Oring Whe Intoxicated) i not minor) Yee _ctefio De you know of any suspension, restriction oF temination of training or professional Brvleges for reasons related to mental or physical impairment. incompetence, meconduct ‘ormalpractice? Yes Scho Boonton wt em ano peso pipes '2 avoid impesiton of ciscipinary measures? ‘Daou know of any confirmed quality problem (quality of hospital care provided te Medicare patients) by the Peer Review Organization (PRO) in Verncnton esewhere? yes So Do you know o fala of ie applicant to compete a residency training program(s)? Yes OT No Dost espace won conse wnenmeies? Keen caeiton © te infomation provided onthe previous page, please use the space below ai the reverse ede for Spa one above and any adstonal infomation you have svaiate tw ai the Seam evolenens oo Shela mean eatcar value lo usin evaluating ary candidate are commentoregarding hes notate ees ines ee msse®: We would apprecinte such comments for you. Any addaanel tlomaton Cheod conte ved to this fom. We reports based on: Giose personal observation Genera impression A composite of facutystaf evaluations Other Speci Mere catty that atthe Ue of completion of he above traning. or during my association withthe physician, helene was competent to pracice medicine and hele was atthe subject o! any Sscpinon oesor ee ee {or licensure in Vermont. ahs E hewec Print or Type Name and Tite:PROGRAM DIRECTOR FORM SEND THREE PAGES‘The Federation of State Medical Boards ‘of the United States, Inc. PO Box 619850 Dalles, Teas 75261-9850, Telephone: (817) 868-1000 PAX(#I7) 868-4089 BOARD ACTION SEARCH RECONCILIATION REPORT June 18, 2002 i Gloria J Hurd ‘Vermont Board of Med. Practice 109 State Street Montpelier, VT 05609-1106 Re: Board Action Query Dated: June 18, 2002 Your Reference Number: s SMB Batch Number: BQ680837 PRACTITIONERS CLEARED WITH NO ACTION AS OF APPLI EARCH DATE em Name pos Schoo! YeiGrad Request 1D 1 Weston, Julia Brock 10/02/1967 46010 1998 so7ais Please refer to prir clearance reports to determine the search date foreach practitioner Page Loot 1‘TheFederationoStaeMediaBords ft nedScae e, “Tego 448.4009 BOARDACTIONCLEARANCEREPORT June18,2002 Ast Glonal urd ‘VermontoardofMed Practice opsiateStet Montpelier, T0S609-1106 Re: BostdActionQuen Dated: Junet8.2002 YourkefernceNomber: —” Fsvnpateuer Bq680837 “TisoowingspunocicchesoniteBoadActonDeBankast Sunet8,2002 fonacsionesibnitotspanfteabowerefeencedbathfrwbichNOboartctonsmecidentie. PrtionensClaetuihNoctinssot Sunet8.2002 1 Weston Juiabrack vwyoanos? oss010 1988 sonsFoRMe, ‘STATE OF VERMONT - BOARD OF MEDICAL PRACTICE Ap; 109 STATE STREET sey MONTPELIER, VERMONT 03600-1106 Say (€02) 628.2673 FORM B: 1) AUTHORIZATION FOR RELEASE OF RECORDS AND INFORMATION ‘AND 2) AUTHORIZATION TO COMMUNICATE WITH FUTURE EMPLOYERS REGARDING THE STATUS OF YOUR APPLICATION. TO WHOM rT May CONCERN: didn brovk bawdall Westin HEREBY AUTHORIZE YOU to fumish to the (Wame of Appicanty Meee ALSO AUTHORIZED to reprt information ether orally or in wing, recy tothe Vermont Board of wing: ete ort designate representative on continuing basis unl Wis autorcatont revokec a, in wang ‘A CONFORMED PHOTOSTATIC COPY OF THIS AUTHORIZATION SHALL SERVE IN ITS STEAD, . 2i ter authorize the Vermont Board of Medical Practice to communicate with future employers andlor locum {enens companies the status of my application for licensure ‘Signature owe HS frope PictorType Name dullA Bkok Rrndne WEST rates; 342 PEARL Gre Ej EE OW. sute zn cove: Buttle Ton vEerusn/T oSYo1 Teteprene Number G02 Scbeced and svom before me ie efi, Nay Faone 7 oie Soar My License Expires AI 2OU: RETURN ORIGINAL TO THE BOARD WITH YOUR APPLICATION SEND COPIES WITH THE REFERENCE FORMSpea ae eed ana aaa te ee ey tequests will be sent directly to the medical licen: director only. To request a Status Re foreign medical school, please complete and retum this form to: ECFMG CERTIFICATION VERIFICATION SERVICE Ce PO BOX 820982 PHILADELPHIA PA 19182-0982 authority or residency proaram port of ECFMG certification for a graduate of a Please type or print. Requests with incomplete or inaccurate information will not be processed. |USMLE/ECFMG Identification Number: fl A Physician’s Name: bla bruh Randell Weston = Teas ‘Theresia Rae Date of Birth: orto | _ oF | de Month Year Name of Medical Licensing Authority: Vermont Board of Medical Practice state Board code: [0] [4] [5] te senttyran on Usa Sp apse Contact: __s._k Johnson Steff Assistant = | [Address to Which Verification ‘Should be Sent *(see above) : 199 s te Street 3 Reese Contnaas Hon pet ier vermont 03603-1106 er ca te com Note: itis the responsibilty ofthe requesting organization to secure and retain the physician's signed suthorization to obtain certification confirmation,‘STATE OF VERMONT, BOARD OF MEDICAL PRACTICE 4109'STATE STREET MONTPELIER, VERMONT 05609-1106 (802) 828.2673 VERIFICATION OF FIFTH PATHWAY _ To be completed by an official of the sponsoring institution: Name of institution: sSERESEEES Address: a ee eee ee eee a $e Uhereby certty that was enrolled in the Fith Pathway Name Program at this institution from. 1 i to ‘Month Day Year Worth Day Year | (Our records indicate that the applicant received a certificate of completion on I po. Worth Bay Year Date: (AFFIX SEAL) ‘Signed: (Offa! of he Sponsoring atiulion) Print Name: ile EEE Se eee eee Telephone Number:State of Vermont Board of Medical Practice THIS IS TO CERTIFY that Julia Brock, M.D. a graduate of the University of Vermont, 1998 faving successfully qualified as a practitioner of medicine before Board has been registered as provided by the Laws of the State. te Fee EDD Elizabeth A. Turner, M.D., 5.D. License Number 42-0010441(00-24! (as}ag- Gea]oo 7 STATE OF VERMONT, BOARD OF MEDICAL PRACTICE, 109 STATE STREET, MONTPELIER: VERMONT os¢084To6 [APPLICATION FOR RENEWAL OF LIMITED TEMPORARY LICENSE, PAGE ONE OF FOUR {hereby apply forthe renowal of my LIMITED TEMPORARY LICENSE tunder the provisions of 26 V.S.A. Section 1391(e). Renewal Fee: $40.00, Fancoephe oy Seabee ios/aynecology Home Address, City, State, Zip Code Burzington, ‘Any applicant wth a dsabilty who needa an accommodation should Gortat the Board office Other states where you are now licensed to practice (ether a training permit or a permanent icense) ‘A~Yos" answer to Questions 1 -24 requires an explanation onthe enclosed Form A. During the past two year: 1 Have you ever applied for and been deniad a license to practice medicine or any healing art? ves Fo 2 Have you ever withdrawn an application fora iense to practice medicine or ny healing ar? Yes "No 3. Have you eve voluntary surendered ot resigned a lcense to practice medicine o any healing atin eu of dsitinary ‘ton? es 2 No 4. Areany ermal escpinary charges pending or has any disciplinary action ever been taken against you by any governmental autor, by any hosal or healt care ast, 0: by any professional medical association (mterational, nator sat o ieeay? aes Who 5 Toyourknowlge, are you the subject oan investigation by any other censing boars as of he dae ths appicaton? we yes No ©. Have you aver been denied the privilege of taking an examination before any State Medical Examining Board? Yes_ Spa te 7 ‘ TaatName Fist Name ‘Widale Nam: ‘Sul b Indicate your name, as ishould appear on your license: Rock SULIA > TastNiame ret Namo TWiadie Name Sut 2 YourDate of Birth: OCTOBER 2, 1967 3. Home Address and email address: 96 Colchester Avenue Burlington, VT 05401 julia.brock@verizon.net 4. Work Address: 96 Colchester Avenue Burlington, VT 05401 julia.brock@verizon.net 5. Please check your preferred mailing address: __ Home _X_ Work NOTE: The mailing address wil be publiciy listed on the Board's web site. 802_)_985~5635, 6. Home Telephone Number with Area Cod 7.Work Telephone Number with Area Code: (__802_) 862-7338 8, Exmall address (if not appearing in #3): julia@maieriobgyn.com Please check here ithe Depariment of Heal may use tis eal address fo Send you pubic heal information, Byes ono.PARTI 8. Were you in active practice in Vermont in the past 12 Months? yes ono 10. Do you hold, of have you ever held, a medical license (including temporary) in any other state? yes ino ¢ It yes, complete the section below and attach additional pages ifnécessary, state License Number Type of License Datelssued Status (Active, Inactive, or other, 2g, conditioned, restricted, limited) None reported ‘ANY "YES" RESPONSE TO THE QUESTIONS BELOW MUST BE FULLY EXPLAINED ON THE ENCLOSED FORMA. 41. Have you ever applied for and been denied a license to practice medicine or any other healing art? yes no i 12, Have you ever withdrawn an application for a license to practice medicine or any other healing art? yes Xno 13. Have you ever voluntarily suspended, surrendered or resigned a license to practice medicine or any other healing art in lieu of disciplinary action? Syes Xno 414, Are any formal disciplinary charges pending or has any disciplinary action ever been taken against you by any governmental authority, by any hospital or health care facility, or by any professional medical association (International, national, state or local)? yes xno lege of taking an examination before any state medical examining eyes Bro 46, Have you ever discontinued your education, training, or practice for a period of more than three months for reasons other than a family need? eyes xno 17. Have you ever been dismissed or suspended from, or asked to leave a residency training program before completion? eyes xno 418, Have you ever had staff privileges, employment or appointment in a hospital or other health ca Institution doniod, reduced, suspended or revoked, or resigned from a medical staff after a complaint or Peer review action was initiated against you? yes xno 18. Has your privilege to possess, dispense or prescribe controlled substances ever been suspended, revoked, denied, or restricted by, or surrendered to any jurisdiction or federal agency at any time? eyes ano 20. Are you presently or have you ever been a defendant ina criminal proceeding? yes anoPART III (Uniess otherwise ordered by a court, your responses to the questions in Part Ill are considered exempt from public disclosure.) Any “yes” response to the questions below must be fully explained on the enclosed Form A. 21. To your knowledge, are you the subject of an investigation by any other licensing board as of the date of this application? 22, To your knowledge, are you presently the subject of a criminal investigation? The folowing definitons are provided to assist you in answering questions 23 through 25, “Ability to practice medicine” - This term inchides 1. The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned medical judgments, and to learn and Keep abreast of medical developments; and 2 The abiity communicate those judgments and medical information o patents and other health care providers, with or without the use of ads or devices, such as voice ampiier. and 3. The physical capability to perform medical tasks such as physical examination and surgical procedures, with or without the use of aids or devices, such as corrective lenses or heaving aids. “Medical condition’ includes physiological, mental or psychological conditions or disorders, such as, but ot limited to, orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular aystrophy, mutiple sclersis, cancer, heart cisease, diabetes, mental retardation, emotional or mental liness, specifi learning disabiltes, hepatiis, HIV disease, tuberculosis, drug addiction, and alcoholism, “Currently” - This term means recenty enough to have a real or perceived impact on one’s functioning as alcensee “Chemical substances" - This term s io be construed to include alcohol, drugs, or medications, including those taken pursuant to a valid prescription for leaitmate medical purposes and in accordance with the prescribers direction, as wel 2s those used illegally “Controlled substances’ - This term means those drugs listed an Schedules | through V of Section 202 of the Contolled Substances Act (21 USC § 812) “illegal use of controlled substances" - This term means the use of drugs, he possession or distribution of which s unlawful under the Controlled Substances Act, as periodically updated by the Food and Drug ‘Administration. This term does not include the use of 2 drug taken under the supervision ofa licensed health care professional or other uses authorized by the Controlled Substances Act or other provisions of federal law. 23, Do you have a medical condition that in any way impairs or limits your ability to practice medicine in your field of ii ‘with reasonable skill and safety? In explaining a “Yes’ answer on Form A, please provide reasonable assurances that your medical condition is reduced or ameliorated because, for example, you have received or do receive ongoing treatment (with ar without medication) or have Participated o: do participate in a monitoring program. | 24, Are you currently engaged in the use of alcohol or other chemical substances that in any way impairs your ability to practice medicine in your field of practice with reasonable skill and safety?|n explaining a “Yes” answer on Form A, please provide reasonable assurances that your Use is feduced or ameliorated because, for example, you have received or do receive ‘ongoing treatment (with oF withoul medication) or have participated or do partaipate in a ‘monitoring program. 25. Are you currently engaged in te illegal use of controlled substances? CONFIDENTIAL ASSISTANCE IS AVAILABLE Since 1999, part of each license fee has been used to creale and maintain the Vermont Practitioners. Health Program, a service of the Vermont Medical Society. This is @ confidential program for the | 'dentication, treatment and rehabiitaion of physicians affected by the disease of substance abuse. For further information about this program, call 802-223-0400 (a confidential ine). PARTIV The following questions are required by Vermont law, 26 VSA § 1368, to update and maintain a date repository within the Department of Health and to make individual profiles on allhealtncare professionals leensed, cetihe, or registered by the Department available to the publi. Your physician profile s located atthe folowing website ito eathyvermont gov Please include pfiotocopies of court papers, licensing authority decisions, and any other relevant documents if your answers to questions 26 through 31 have changed since your last application. We ‘cannot process your application without them. 26. Criminal Convietions (26 VSA § 1968(a\(1)] _¥ Check here i none Please provide @ description of ali crimes (felonies and misdemeanors; ths includes DUI but not speeding Or parking tickets) of which you have been convicted within the past ten years not listed below. Please provide complete copies of documentation for each matter. None reported (Conviction Datey (Coury Cnsiay (eamey 27, Nolo Contendere/Matters Continued [26 VSA § 1368(a)(2)] fi Check here I none Please provide a description of all charges to which you pleaded “nolo contendere” (‘I will not contest i) or where sufficient facts of guit were found and the matter was continued withou! a finding by a court of Competent junsdiction not Iisted beiow. Please provide complete copies of documentation for each matter. None reported t (Conviction Date) (Coury (CiySiatey (charge 28. Vermont Board of Medical Practice Matters [26 VSA § 1358(a)3)) _ # Check here none Please provide a description of all formal charges served, findings, conclusions, and orders of the Board of ‘Medical Practice including stipulations), and final disposition of such matters by the courts, appealed