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West Virginia Board of Medicine Quarterly Newsletter Volume 14, Issue 1 January 2010 March 2010 LEGISLATIVE UPDATE 2010 Senate Bill 372 passed, was signed by the Governor, and will take effect on June 11, 2010. The bill updates a few sections of the Medical Practice Act, which needed to be modernized, in some instances thirty (30) years after their enactment. “Surgery,” which has never been defined in state law, is now declared to include “the use on humans of lasers, ionizing radiation, pulsed light and radiofrequency devices.” The law removed the requirement for balancing political party membership when the Governor makes Board of Medicine appointments and specifies that the expiration, surrender, or revocation of the professional license of a Board member by the Board of Medicine shall cause the Board membership to immediately and automatically terminate. “Electronic means” are added as a method the Board may use for notification purposes. The outmoded term “State Director of Health” has been replaced with “State Health Officer.” INSIDE THIS ISSUE Legislative Update 2010 1 Board Member Profile 2 2010 Renewal Reminder for Supervisors and PAs 3 Board Actions 4-5 HAI Prevention Reminder to PAs Board Members 6 Request for Paper Application 7 “The Public Member” 8-9 Newsletter Via E-Mail PA and PA Supervisors Board Staff 10 Change of Address Form 11 Change of Address Info Board Meeting Dates 12 Senators Foster, Jenkins, and Stollings, three (3) of the sponsors of Senate Bill 372, were also sponsors of several bills enacted to assist in combating drug diversion. They were signed by the Governor, as follows: Senate Bill 81, effective June 9, 2010, requires prescriptions to be written on official tamper-proof prescription paper in order to reduce the epidemic of prescription drug fraud. A Board of Pharmacy rule will be enacted to implement the provisions. Practitioners are required to make reports of any loss, destruction, theft or unauthorized use of any official prescription to the Board of Pharmacy. The new law does not apply to oral, electronic or out-of-state prescriptions, nor does it apply to prescriptions generated within a licensed medical facility resulting in the internal dispensing of prescription drugs to a patient receiving treatment in that facility where the patient is never in possession of the prescription. Committee Substitute for Committee Substitute for Senate Bill 365, also effective June 9, 2010, requires that by July 1, 2011, all prescribers or dispensers of Schedule II, III or IV controlled substances have online or other form of electronic access to the West Virginia Controlled Substances Monitoring Program database, authorizes the Chief Medical Examiner access to the database, limits liability of practitioners for good faith reliance on the database, and specifies that practitioners are not required to access the database. The Board of Pharmacy will promulgate an emergency rule to implement the provisions. Senate Bill 514, effective June 3, 2010, amended a statute requiring controlled substance reporting when a prescription is filled for a controlled substance or a controlled substance is dispensed. In both cases, the reporting requirement applies to Schedules II, III and IV, and now to both the filling of such a prescription and the dispensing of the controlled substance. The Board of Pharmacy will promulgate a rule to implement the provisions. Committee Substitute for Senate Bill 362, effective June 11, 2010, increases the penalties for unlawfully withholding information from a practitioner in order to obtain a prescription for a controlled substance. Volume 14, Issue 1 Page 2 BOARD MEMBER PROFILE Rusty L. Cain, D.P.M. In October 2009, Rusty L. Cain was appointed to the Board of Medicine by Governor Joe Manchin, III. Dr. Cain lives in Fairmont, West Virginia, and fills one of two podiatrist seats on the fifteen member Board. After graduating from Waynesburg College in Waynesburg, Pennsylvania, where he grew up, Dr. Cain received his Doctor of Podiatric Medicine in 1997 from the Ohio College of Podiatric Medicine in Cleveland. His Podiatric Surgical Residency was at Community General Hospital in Thomasville, North Carolina, and he is Board Certified in Foot Surgery by the American Board of Podiatric Surgery. He has been practicing podiatry in Fairmont for more than a decade. Dr. Cain enjoys medical staff appointments at Fairmont General Hospital, Fairmont General Wound Healing Center, and Health South Rehabilitation Center. At Fairmont General Hospital, Dr. Cain for three years was a member of the Medical Executive Committee and Chair of the Department of Surgery. Since 2006, he has been a member of the Infection Control Committee. Dr. Cain is a member of both the American Podiatric Medical Association (APMA) and the West Virginia Podiatric Medical Association (WVPMA). He was Vice President of WVPMA for four years prior to becoming its President from July 2006 through July 2008. Dr. Cain was the Chief West Virginia Delegate to the House of Representatives of the APMA in 2004. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery. Dr. Cain is a member of OPEIU Guild 45, a health care branch of the AFLCIO, and he is a Board Member and currently Treasurer of HOPE, Inc., a regional Task Force on Domestic Violence. He is active in the Rotary Club of Fairmont, where he recently served as President. Dr. Cain and his wife of sixteen years have two daughters, ages 6 and 4. He enjoys spending time with his family and enjoys running. Recently, he has taken up the sport of snowboarding. Volume 14, Issue 1 Page 3 2010 RENEWAL PROCESS Medical Doctors A - L Only those medical doctors whose last names begin with the letters A through L are required to renew for the years 2010 - 2012. For the years 2010 - 2012, the Board of Medicine will not be mailing a paper renewal application to all the medical doctors who are renewing their licenses. Beginning May 13, 2010, licensees who meet the criteria for online renewal may go to the Board’s website at www.wvbom.wv.gov and follow the online renewal directions. The criteria are as follows: 1. 2. 3. 4. currently hold an ACTIVE medical license; currently hold an INACTIVE medical license and will renew in an INACTIVE status; have obtained the required continuing medical education; answer “no” to all questions (see “Renewal FAQ’s” currently on the Board’s website); and 5. desire to pay via credit/debit card. If a licensee is unable to use the online renewal service, he or she will need to request a paper renewal application to complete and return to the Board offices. The online application or paper application must be completed and submitted BEFORE Wednesday, June 30, 2010, at 4:30 p.m. A request form for a paper renewal application is available on our website under the “FORMS” section and is also available in this Newsletter on page 7. CHANGES TO THE UPCOMING RENEWAL PROCESS • • • Medical doctors who currently hold an inactive license and will remain in an inactive status may now renew online, provided they meet the above-outlined criteria. Page three of the renewal application pertaining to continuing education requirements has been changed to include two separate certifications of compliance—one for the 50 hours of continuing education and one for the 2 hours of continuing education coursework in end-of-life care, including pain management. The Board hopes this change will alleviate the misrepresentations found during random audits of continuing education. Beginning July 1, 2008, at least thirty (30) hours of the required fifty (50) hours of continuing education must be related to the physician’s area or areas of specialty. REMINDER FOR SUPERVISING PHYSICIANS AND PHYSICIAN ASSISTANTS When terminating a supervisory relationship with a physician assistant, a supervising physician is required to notify the Board in writing within ten (10) days of such termination (see 11 CSR 1B 9.2). When the information is received, the Board will note the change on the physician assistant’s permanent record immediately. The Board has no responsibility to inform the physician assistant of any change to his or her record or license status. The nature of the physician assistant/supervising physician relationship is one that should facilitate such communication between the two (2) professionals. It is appropriate for the physician assistant to also inform the Board of any changes to his or her work location or supervision. Volume 14, Issue 1 Page 4 BOARD ACTIONS January 2010 — March 2010 BROWN, DEBORAH, P.A.-C. – Nallen, WV (01/25/2010) WV License No. 01199 Board Conclusion: Failure to comply with the provisions of West Virginia Code § 30-3-16(r) and 11 CSR 1B 14.1, relating to physician assistants. Board Action: PUBLICLY REPRIMANDED for writing prescriptions with no authority to do so having been granted by the Board. DUFFY, TRESSIE MONTENE, M.D. – Martinsburg, WV (02/24/2010) WV License No. 19978 Board Conclusion: Relating to dishonorable, unethical and/or unprofessional conduct; failing to perform any statutory or legal obligation; filing a report the licensee knows to be false; failing to practice medicine acceptably, and otherwise violating the law; relating to making a deceptive, untrue or fraudulent representation in the practice of medicine and surgery; and relating to conduct which is calculated to bring or has the effect of bringing the medical profession into disrepute. Board Action: PUBLICLY REPRIMANDED for her misdemeanor conviction and for her multiple poor judgments leading to the circumstances underlying the criminal charge and conviction; and shall undergo regular, individual psychological counseling by a Board-approved licensed mental health professional for a period of eighteen (18) months, who shall provide written quarterly reports to the Board. FEATHERS, SCOTT JAMES, D.P.M. – Parkersburg, WV (01/11/2010) WV License No. 00181 Board Conclusion: Relating to unprofessional, unethical and dishonorable conduct; improper prescribing of controlled substances; inability to practice podiatry with reasonable skill and safety; and exploiting patients for financial gain. Board Action: License SUSPENDED effective January 12, 2010, at 12:01 a.m., with a Notice of Hearing for January 23, 2010. Respondent’s Waiver: By Respondent’s Waiver entered January 21, 2010, Dr. Feathers waived that the hearing be held on January 23, 2010, and that until such time as a hearing is held and an order entered by the Board, his license shall remain in a suspended status indefinitely. GUO, WEIXING, M.D. – Charleston, WV (03/08/2010) WV License No. 20962 Board Conclusion: Unprofessional, unethical and dishonorable conduct. Board Action: Effective March 8, 2010, the STAY of REVOCATION placed upon Dr. Guo’s West Virginia medical license was lifted; and accordingly, Dr. Guo’s license is REVOKED pursuant to the terms of the February 11, 2009, Consent Order and is effective March 8, 2010. HABASHI, MAHER F., M.D. – Lincolnton, NC (01/13/2010) Board Conclusion: Reckless disregard for the accuracy of the information he submitted to the Board. Board Action: License APPROVED with a PUBLIC REPRIMAND and an ADMINISTRATIVE FINE of $1,000. Court Action: Dr. Habashi filed an appeal of the Board’s Order with the Kanawha County Circuit Court on February 12, 2010. MOORE, DAVID ALLEN, P.A.-C. – Beckley, WV (03/26/2010) WV License No. 00877 Board Conclusion: The commission of any act involving moral turpitude, dishonesty or corruption. . .and prescribing a controlled substance under state or federal law, to or for himself. . . Board Action: License GRANTED effective March 26, 2010, under specified terms, for a period of six (6) months, automatically expiring and terminating September 30, 2010, at 11:59 p.m. OVERMILLER, CARL LEE, M.D. – Daniels, WV (03/29/2010) WV License No. 17934 Board Conclusion: Prescribing, dispensing, administering, mixing or otherwise preparing a prescription drug, including any controlled substance under state or federal law, other than in good faith and in a therapeutic manner in accordance with accepted medical standards; and inability to practice medicine with reasonable skill and safety due to physical and mental impairment. Board Action: REPRIMANDED for his prescribing of a prescription drug other than in good faith and for his gross negligence in the use and control of prescription forms and must fully comply with conditions, limitations, and accommodations for a period of three (3) years. continued on page 5 Volume 14, Issue 1 Page 5 BOARD ACTIONS January 2010 — March 2010 continued from page 4 RICE, JOHN F., P.A.-C. – Dunbar, WV (01/26/2010) WV License No. 00678 Board Conclusion: Relating to unprofessional conduct. Board Action: License GRANTED effective February 1, 2010, for a period of fourteen (14) months, under specified terms. SADORRA, LAGRIMAS, M.D. – Cross Lanes, WV (03/05/2010) WV License No. 12801 Board Conclusion: Relating to dishonorable, unethical, and unprofessional conduct; failing to perform a statutory or legal obligation placed upon a licensed physician; violating a lawfully promulgated rule of the United States; and engaging in conduct which has the effect of bringing the medical profession into disrepute. Board Action: As conditions to Dr. Sadorra’s suspended license to practice medicine in the State of West Virginia being returned to an active status, she shall, within a one (1) year period, complete fifty (50) hours of continuing medical education and provide proof of the same to the Board and shall take and pass the Special Purpose Examination (SPEX) and provide proof of the same to the Board. If, and only if, Dr. Sadorra has met these conditions, her license will be returned to an active status subject to a period of PROBATION for two (2) years, with conditions. THOMAS, RONALD LEE, M.D. – Pittsburgh, PA (03/15/2010) WV License No. 20749 Board Conclusion: Relating to presenting false statements in connection with an application for a license. Board Action: Dr. Thomas is granted ACTIVE status for his currently automatically suspended license to practice medicine and surgery in the State of West Virginia and shall pay $300 for providing false information to the Board on two (2) applications submitted to the Board, $200 of which is designated a fine for his deficiency of two (2) hours of continuing medical education in end-of-life care including pain management, and $100 of which is designated administrative costs. TIMBAYAN, ADIN L., M.D. – Montgomery, WV (02/01/2010) WV License No. 11489 Board Conclusion: Delegating professional responsibilities to a person when the physician delegating such responsibilities knows or has reason to know that such person is not qualified by licensure to perform them. Board Action: PUBLICLY REPRIMANDED for supervising a physician assistant while the physician assistant was writing prescriptions with no authority to do so having been given by the Board. WILLS, DANNY RAY, M.D. – Princeton, WV (03/08/2010) WV License No. 10582 Board Conclusion: On August 27, 2009, Dr. Wills entered a plea of guilty in the United States District Court, Southern District of West Virginia, to one (1) count of acquiring and obtaining possession of a quantity of hydrocodone by misrepresentation, fraud, deception and subterfuge, ending May 5, 2009. Board Action: Under the provisions of West Virginia Code, the Board shall revoke the license of any physician who is found guilty by any court of competent jurisdiction of any felony involving prescribing, selling, administering, dispensing, mixing or otherwise preparing any prescription drug, including any controlled substance under state or federal law, for other than generally accepted therapeutic purposes. Accordingly, the Board REVOKED the license to practice medicine and surgery of Dr. Wills effective March 10, 2010. REVOCATION OF MEDICAL CORPORATION CERTIFICATES 4M Emergency Systems of West Virginia, Inc. - March 8, 2010 River Valley Pathology, Inc. - January 11, 2010 Volume 14, Issue 1 Page 6 Healthcare Associated Infection (HAI) Prevention Join the Campaign! In February 2009, an outbreak of pneumonia and invasive Streptococcus pneumoniae was reported in a West Virginia nursing home resulting in as many as 11 deaths. In May 2009, an outbreak of invasive Staphylococcus aureus was identified in association with an outpatient clinical practice. An outbreak of hepatitis B was identified in November 2009 in association with a large dental clinic. Like all healthcare associated outbreaks, these outbreaks were costly in lost revenue, patient health and provider peace of mind. The West Virginia Department of Health and Human Resources, Infectious Disease Epidemiology Program, invites you to join the campaign against these devastating preventable infections. The West Virginia Healthcare Associated Infections Plan is now available for review at: http:// www.wvidep.org/HealthcareAssociatedInfections/tabid/1912/Default.aspx. The plan was developed with the assistance of a multidisciplinary advisory group. Membership is listed at that website. Please join the fight against healthcare associated infections. Do it for your patients and your peace of mind. REMINDER TO PHYSICIAN ASSISTANTS By law, all applications and associated required material must be received at the Board offices fifteen (15) days prior to a Board Meeting (see 11 CSR 1B 4.1). If you have a concern regarding a start date for work, please contact the Board’s Physician Assistant Coordinator, Wendy L. Greene, at 304.558.2921, Ext 210. West Virginia Board of Medicine Board Members John A. Wade, Jr., M.D., President Point Pleasant Beth Hays, M.A. Bluefield J. David Lynch, Jr., M.D. , Vice President Morgantown Cheryl Henderson, J.D. Huntington Catherine Slemp, M.D., M.P.H., Secretary Charleston Carlos C. Jimenez, M.D. Glen Dale R. Curtis Arnold, D.P.M. South Charleston Vettivelu Maheswaran, M.D. Charles Town Rev. Richard Bowyer Fairmont G. Mark Moreland, M.D. Nitro Rusty L. Cain, D.P.M. Fairmont Badshah J. Wazir, M.D. South Charleston Michael L. Ferrebee, M.D. Morgantown Kenneth Dean Wright, P.A.-C. Huntington M. Khalid Hasan, M.D. Beckley Volume 14, Issue 1 Page 7 **REQUEST FOR PAPER RENEWAL APPLICATION** 2010 – 2012 Medical Doctors A - L I am requesting that a paper renewal application be mailed to the address printed below. Please note that the paper renewal application will be mailed to you on May 13, 2010. LICENSEE’S NAME_____________________________________________ MAILING ADDRESS_____________________________________________ _________________________________________________________ _________________________________________________________ City State Zip Licensee’s Original Signature___________________________ Licensee’s WV Medical License No______________________ Today’s Date______________ Complete the above information and mail or fax to: West Virginia Board of Medicine 101 Dee Drive, Suite 103 Charleston, WV 25311 Fax: 304.558.2084 Volume 14, Issue 1 Page 8 THE PUBLIC MEMBER: A SIGNIFICANT PRESENCE IN PROFESSIONAL LICENSING Reverend O. Richard Bowyer Although generally common today, the phenomenon of selecting public, lay or consumer members to serve on professional licensing boards is a rather recent reality. In many cases the initial appointments were often virtually mere tokens, usually one layperson on a board of perhaps as many as 12 or more. As the value of such persons became increasingly known, the number of such appointments also tended to increase. During the dynamic decade of the 1960s various social movements began to clamor for consumers to serve on various boards of directors, especially in the non-profit arena. Federal agencies and other funding bodies began to require such inclusiveness as a condition of grant recipients. But for professional licensing boards, the inclusion of laypersons was often legislatively driven. My personal experience has been in two areas: The Board of Medicine and the Lawyer Disciplinary Board. In West Virginia, the Board of Medicine is established by State Code, while the Lawyer Board is appointed through the State Bar and its disciplinary actions enforced by the Supreme Court. In both instances, those who serve as public or lay members play a very significant role. Even so, a newly appointed layperson often is unsure of her or his role and opportunities to make special contributions to the process of licensing and discipline. It must be recognized that the status of a layperson is the same as that of any professional person on the board. Certain things are, or should be, obvious. Most important is the fact that a layperson is not and should not be expected to be qualified to offer judgments on matters that require professional knowledge and competence. There will be matters that have technical implications that the layperson need not know nor understand. However, many of the matters before the board will benefit from other competencies and experience. I have found that with both lawyers and doctors there are issues that appear differently to the eye and from the experience of a layperson. A layperson may perceive waiting time or what the professional may consider to be an appropriate comment quite differently. Quite often there are ethical questions and considerations or matters of common courtesy that need to be addressed. A layperson may or may not bring experience in dealing with the particular profession in any capacity than as a recipient of services. But she or he may have experience serving on other boards and therefore have clear understanding of procedural protocols such as parliamentary rules. When the particular professional board has concerns to be presented to the Legislature of a State, the lay voice may carry particular weight and influence. It is very important for the layperson to understand the public tendency to view professional licensing boards to be protectors of the profession. Although in agencies established by legislation, such as a Board of Medicine, it is clearly articulated that its primary responsibility is to protect the public; there are those who assume that with a majority of the board being members of the profession, they will think first of its well being. But professionals in any field who understand the role they play in society know that the public or the patient should be and must be their primary consideration. It is essential for a layperson to know and understand the primary role of the board and to challenge any situation that might in reality or perception stray from that purpose. continued on page 9 Volume 14, Issue 1 Page 9 THE PUBLIC MEMBER: A SIGNIFICANT PRESENCE IN PROFESSIONAL LICENSING Reverend O. Richard Bowyer continued from page 8 There are, or there are likely to be, situations in which members of the profession perceive a given matter as being in the public's best interest, when the layperson has a different view. It is essential that the layperson speak up and articulate his or her experience, knowledge or personal perception. In a recent training session of the board of directors of a community mental health agency provided by an auditor, the auditor stressed that the most important thing a board member can do is ask questions. That may not necessarily be the case in professional licensing and disciplinary matters, but appropriate questions can be very helpful in making decisions or recommendations. In fact, there may occasionally be a professional member of the board who is not accustomed to having his or her views questioned especially by someone outside the profession. A timely and intelligent question from a layperson may be a significant teaching moment for both parties. Especially in matters of discipline the layperson may offer an insight into the complaint and raise a question that reflects his or her personal experience in a similar situation. There are other situations in which a clear statement or thoughtful question can be very helpful. Even with legal documents and procedures, the layperson may offer a perspective that can be quite beneficial. In formal or official letters or statements, a lay viewpoint may be quite significant. When reviewing drafts of documents or formal statements, the eye less familiar with the technical language may very well catch a spelling or grammatical error. It is essential that the layperson, no less than any professional member, recognize that all statements and public expressions of the board must be made only by the person or persons authorized to speak on behalf of the board. Actions are board actions and whatever has been decided or determined by the majority of the board is the official action or position of the board. Disagreement may be quite appropriately expressed in the process of reaching a decision or determining an action. But once made, that action is official and disagreement is seldom appropriate to express outside the board. In most cases, board meetings are likely to be conducted in public or open session. No less than professional members of the board, a layperson may occasionally have a conflict in a matter. For example if it involves a professional who has provided services to the layperson in normal circumstances, or if the professional happens to be employed or engaged by an agency for which that layperson is a board member, a conflict should be declared and the layperson recused from the action. Membership on a professional licensing board is not only a notable honor, it is an opportunity to contribute significantly both to the profession the board represents, and even more to the public that profession exists in order to serve. Volume 14, Issue 1 Page 10 PLEASE READ IMPORTANT REQUEST If you would like to receive future copies of the Board’s quarterly newsletter via e-mail notice instead of receiving a paper copy through the mail, please e-mail us at wvbomnewsletter@wv.gov advising us of your name and e-mail address. Beginning with the April - June, 2010, issue of the newsletter, you will receive an e-mail notice from the Board that the current issue is available and you will be given a link to view the newsletter. In the future, all newsletter notices will be sent to you via e-mail. This will reduce costs for printing, copying and postage, reduce staff time, and is in line with the process of the Board “going green.” Be sure to keep us apprised of any change in your e-mail address. Physician Assistants and Physician Supervisors: Pay Attention Recently, physician assistants have been disciplined by the Board of Medicine for writing prescriptions without any authority to do so. Their supervising physicians have been disciplined as well. In each case, the physician assistant prepared an application, relied on others to submit the application to the Board of Medicine, and failed to follow through to ensure not only that the submission had been made but that the Board of Medicine had granted the request. The physician assistants then commenced writing prescriptions. This is a serious issue. The prescriptions are not lawful. First, it is the responsibility of the physician assistant and the supervising physician to ensure that applications are submitted to the Board in a timely manner. Second, it is the responsibility of the physician assistant and the supervising physician to do only what has been authorized by the Board. Third, it is the responsibility of the physician assistant and the supervising physician NOT to do what has not been authorized by the Board. Staff of the West Virginia Board of Medicine 304.558.2921 Ext # 227 Robert C. Knittle, M.S. Executive Director 214 Deborah Lewis Rodecker, J.D. General Counsel 215 John A. Lohmann, J.D., M.B.A. Disciplinary Counsel 211 Lori Blaney Paralegal 212 M. Ellen Briggs Administrative Assistant to the Executive Director 210 Wendy L. Greene Physician Assistant Coordinator 216 Michael R. Lilly Information Systems Coordinator 213 Charlotte Ann Pulliam Complaint Coordinator 220 Deborah D. Scott Fiscal Officer 221 Sheree J. Thompson Licensure Analyst 222 Leslie A. Thornton, CMBI Investigator 224 Teresa L. Westfall Receptionist/Certification and Verification Coordinator Volume 14, Issue 1 Volume 10, Issue 1 Page 11 CHANGE OF ADDRESS FORM NAME:__________________________________________________________________ LICENSE#:__________________ (Last) (First) (Middle) By law, you must keep this office apprised of any and all address changes. PREFERRED MAILING ADDRESS (Required): (Suffix) If not currently practicing, check here □ HOME ADDRESS: □ Check here if same as preferred mailing address (This address is public information, except phone & email) ________________________________ Address 1 __________________________________ ________________________________ Address 2 __________________________________ ________________________________ City, State, Zip, County________________________________ ________________________________ Phone __________________________________ _______________________________________ Email _________________________________________ MAIN WORK ADDRESS: □ Check here if same as preferred mailing address Enter average weekly on call hours for ALL locations:_____________ ________________________________ Address 1 ________________________________ Address 2 ________________________________ City, State, Zip, County ________________________________ Phone Fax ________________________________ List AVERAGE HOURS worked per week (not on call) at this location: Direct Patient Care:___________ Administration:____________ Formal Teaching:____________ Research:____________ Other Medical/Podiatric Activities:___________ Email SECOND WORK ADDRESS: ________________________________ Address 1 ________________________________ Address 2 ________________________________ City, State, Zip, County ________________________________ List AVERAGE HOURS worked per week (not on call) at this location: Direct Patient Care:___________ Administration:____________ Formal Teaching:____________ Research:____________ Other Medical/Podiatric Activities:___________ Phone THIRD WORK ADDRESS: ________________________________ Address 1 ________________________________ Address 2 ________________________________ City, State, Zip, County ________________________________ Phone List AVERAGE HOURS worked per week (not on call) at this location: Direct Patient Care:___________ Administration:____________ Formal Teaching:____________ Research:____________ Other Medical/Podiatric Activities:___________ Enter your self-designated primary and secondary SPECIALTY here: (M.D.’s and D.P.M.’s ONLY) Primary Specialty: _________________________ Secondary Specialty: _________________________ LICENSEE’S ORIGINAL SIGNATURE:___________________________________________________ DATE:_________________ RETURN FORM TO: West Virginia Board of Medicine, 101 Dee Drive, Suite 103, Charleston, WV 25311 Page 12 Volume 14, Issue 1 CHANGE OF ADDRESS INFORMATION NOTE: There is a Change of Address Form located on Page 11 of this Newsletter. You may also visit the Board’s website at www.wvbom.wv.gov for a Change of Address Form. By law, a licensee of the Board of Medicine must keep this office apprised of any and all address changes. The preferred mailing address of a licensee is the licensee’s address of record, which is public information, with the exception of the telephone number and e-mail address. WEST VIRGINIA BOARD OF MEDICINE 2010 MEETINGS May 10 July 12 September 13 November 8 ALL BOARD MEETINGS BEGIN AT 9:00 A.M. WV Board of Medicine PRESORTED STANDARD US POSTAGE PAID CHARLESTON, WV 25301 PERMIT NO. 271 101 Dee Drive, Suite 103 Charleston, WV 25311 Phone: 304.558.2921 Fax: 304.558.2084 Place Mailing Address Label Here www.wvbom.wv.gov Watch for updates and changes.