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  • Andrea Arena, M.D.'S Massachusetts Licensing Applications

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    ABORTIONIST ANDREA ARENA, M.D.'S MASSACHUSETTS LICENSING APPLICATIONS. SHE LISTS PLANNED PARENTHOOD AS HER WORKPLACE.

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    ANDREA ARENA, M.D.'S MASSACHUSETTS LICENSING APPLICATIONS

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    ABORTIONIST ANDREA ARENA, M.D.'S MASSACHUSETTS LICENSING APPLICATIONS. SHE LISTS PLANNED PARENTHOOD AS HER WORKPLACE.

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    © All Rights Reserved
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    46 vues18 pages

    Andrea Arena, M.D.'S Massachusetts Licensing Applications

    Transféré par

    RAAB2532
    ABORTIONIST ANDREA ARENA, M.D.'S MASSACHUSETTS LICENSING APPLICATIONS. SHE LISTS PLANNED PARENTHOOD AS HER WORKPLACE.

    Droits d'auteur :

    © All Rights Reserved
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    a Tee po -200f jee lj 4-08 ReDacten copy vd DW tem | QoS 3& SOD OF RESIST g ¥ Application #: 22/0. Date of lesue: —~——lwneniene Common th of Massachusetts - Board of Registration in Medicine 10 West Street, 3rd Floor Boston, MA 02111 - (617) 727-3086 LL LICENSE APPLICATION Application Fee: Please enclose a check ot money order in the amount of $360 made payable to the Commonwealth of Massachusetts, Check One: xq U.S/Canadian Graduate C International Graduate Legal Name (do not use nicknames or initials, unless they are part of your legal name) ARENA ANDREA ELIZABETH, TSR Name peor pin cea) Fest Tia Sa acy JAMo0. O Do. O PhD CO Other degree. Other Name(s} Used. - List any other name(e) you have used which may appear on your identiying Boston 6. Name of Facility 7. Address: City: 8. Anticipated starting date in Massachusetts: 1 2y 15 10 Affidavit of Applicant |, the undersigned applicant, hereby certify that all information included in this application for licensure constitutes a true statement made under the penalties of perjury. OWdrer © -Oneno- 4/5/0) Signature of Applicant Date SUPPLEMENT FORM Name: Andrea Arena pace: 4 15/0] IMPORTANT NOTE: Ifyou answer “yes” to any of these questions, you must provide the additional information ou pages 4-10. 1, Since your enrollment in college, have you been subject to any disciplinary action (see definition) at an academic institution? 2, Have you ever been terminated ot granted a leave of absence by a medical school or medical ‘Post-graduate training program or have you ever withdrawn from a medical school ot ‘medical postgraduate training program or had to repeat a year of postgraduate training? 3. Haveyyou ever applied for licensure or to sit for an examination or taken an examination under different name? If so, previous name: 4, Since your enrollment in college, have you boon denied the privilege of teking or finishing fn examination or been accused of cheating and/or improper conduct during an examination? 5S. Have you ever failed any of the following examinations: FLEX, any State Board ‘examination, any part ofthe National Boards, eny Step of the USMLE, or have you failed to gain certfiestion from the National Board of Medical Examiners or any forcign licensing ‘or certification body? GA. Have you ever, for any reason, been denied a medical license, whether full, limited, temporary, or have you withdrawn an application for medical licensure? GB. Haveyou ever voluntarily surrendered a license to practice medicine or any healing art? 7. Have you ever, for any reasoa, lost American Board of Medical Specialty certification ‘or been denied required recertification by one or more specialty boards? 8A. Are any formal disciplinary charges pending against you, or do you have knowledge of any ponding investigation into your professional competence or conduct by any ‘governmental authority, health cae facility, group practioe or professional medical society or association (international, nation, state or local)? (See definition). 8:B, Has any disciplinary action ever been taken against you for violation of law, rules, by-laws, or standards of practice by eny governmental authority, heelthcere facility, group ot ‘professional medical society or association (national, state or local)? YES NO Page 1 ‘Commonwealth of Massachusetts Board of Registration in Medic] = <_, Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086 hutp:fwww.massmedboard.org Physician Registration Renewal Application Before proceeding, you will + Remit $250.00 for renewal fee. | Retufl| renewal application in GREEN envelope. + Add late fee of $25.00, if necessary. elas} chock with coupon in BLUE envelope. Pease review cael the flowing fe TERESI ony conptcenes Hote ny conection r alterations as required 1. Current Stas: pctive Registration No. 19559 Renewal Date: 02/2001 ‘Ifyou waut to change your curent status, please check one ofthe following boxes to indicate your new status: (Check only one) Ghactive Retiring (se instructions) inactive (se instructions) Do not wish to renew Please make correetions (type or pint) (Other Name() 2 Other Name(s), ifany, under which you were licensed 3. A) Malling/Business Addeess: Mating Adres: ‘Andrea E Arena s City/Town: Site zip: County: [Business Address CityrTowa: Zips Country: Busincss Telephones ) 1B) Home Address: ian Sate ome A CinrTow Ta zi Coan Home Poe: |Home Telephone: Business Phone: (6173983-1703 PLEASE NOTE: No P.O. Box addresses for home or Disaes birees arent Arc os of Medical Spcians Coif (Se THE?) apenas —_ Cine of Mele Species Cenitenon (Tae) at py esse 8. Drug License Numbers, any: 5, a) Name of Medical Schoa!: 2) Federal (DFA) ) Massachusets: Set eee wy VERRIER Mel go wher yu ren ee wpe (bh) 6. Specialty Code(s) (See Table 1) Code(s) Hours ver Week in Mass. by States where you were previously licensed (Abbr) FP 0 Family Practice 0 10. Current health care facilities a which you have complete the credentialing proces forthe provision of patieat care. (Supply the codes from Table 3 and place a check mark next to the health care facies where you have admiting privileges (AP), Next to cach facility, write the approximate percentage of patient care hours hat you provide un each facility}. Facility Code:_ |_(AP)__ % Facility Code: (— (AP) % Faity Code: Bes a (AD) a Ee (CAP) 16999, prin nainets) paint vourtast name: ALENG uicensr numer: 2/0538 ~ |, My medical malpractice insurance is covered by a) oy Insurance Carrier») C]_ Letter of Credit . Name of insurer: wned faveuthoo. Ane Alternatively, indicate as follows: 1 am registering wih Active status but Iam not covered by medical malpractice insurance because Iam (check one) 2) (Not involved in direcvVindirect patient care in Massachusets ») [Otherwise ‘exempt Please explain exemption, so _ Dore t NA Vow 12. Are you currently in a post-graduate training program in Massachusetts as a resident or clinical fellow? (check onc) [-] Yes no 13, A, Whats your principal work sting? (See Table 4) 25 B. Care of patients in Massachusets (ee iatraction booklet). avenge wee toursinvohediny ——s)oupatientene _@ sink b)inpaenrcre __hsvi 2) What ste approximate percentage of our patient care hous a primey eae? 100% PART A - QUESTI FER. IE PAST TWO (2) Y1 " nm eck ther VES or NO Ov haueston, Pre tal ste sagenforauenton 22 Refer tela al isformaon ators a aed yrs ae YES NQ| 14, CLAIMS MADE: Has any medical malpractice claim been made against you tat has not yet beea finaly settled or adjudicated, whether or not a lawsuit was filed in relation to the claim? 15, CLAIMS RESOLVED: Has ny medical malpractice claim tat has been made against you been sted, ‘adjudicated, or otherwise resolved, whether or nt lawsuit was fled in relation to the claim? 16. Has any lawsuit other tha a medical malpractice suit, which i elated 1 your competency to practice medicine, «your professional conduct in the practice of medicine, been fled against you or been setted,adivdicated or ftherwate resolved? 17, Have you been carged with any criminal offense, other than a minor traffic vitation? : 18. Have you been clirged with or disciplined for aivolation of laws, rues, by-laws or standards of practice of any governmental authority, healt care failiy, group practice or professional society or association? 19, Has your privilege to posses, dispense or prescribe conrlled substances been suspended, revoked, denied, resticted by, or surrendered to any state ot federal agency? 20. Have you withdrawn an application fora medical license or been denied a medical license for any reason? 21. Has any profesional ability insurance provider restricted, limited terminated, imposed a surcharge ot co-payment, or placed any condition related to professional campetency or conduct on your coverage or have you voluntarily rescted, limited or erminaed your insurance coverage in response to an inqut) by & ‘professional liability insurance provider? 22. CME CERTIFICATION: Have you completed your CME requirements preceding your renewal dae? [XJ Yee [No Cy CME Waiver requested (CME waiver form de 30 days prior 10 date of cease expiration) ___) CME exemption "=~ See Tidtructon® for CME Fefairements, Do not subsnit documentation of your CMEs with your renewal appliat Pursuant to GL. c.112,§2 1 wil at charge to or cole froma Medicare beneficiary more than the Medicare fe schedule amount. Pursuant fe GL: c.62C, §49A, tothe bes of my knowledge and belie have filed all Massachusetts state tax eters and pad all Mazeachasts tate ars that are required under law. NOTE: Thisapplies eve you reside outofstateor out ofthe Uted Stats + Pursuant to GL 6. 2, §47A,t0 the best of my knowledge and beef am in compliance with M.G.HLC. 119A relating to tithholding and remitting Child Support. + Pursuant t0 GL 12,5 14, Lil fulfil my obligation to report abs or neglect of children es required by GL. e119, 514. + Thereby certify under the penalties of perjury hat ol the information onthe Renewal Application and Form R is true Signe dudrea Careno~ pee: 103 Of x siGt INCL iT! ‘OUR RENEWAL JON Board Regulations require that vou notify the Board, in writing, of any change of address 2 MAKE A COFY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. Commonwealth of Massachusetts Board of Registration in Medicine 560 Harrison Avenue, Suite #6-4, Boston, MA. 02118 ~ (617) 684-9810 btp:/wmw.massmedboard.org Physician Registration Renewal Application Ty DEC -amr Before proceeding, please read the Instruction booklet. i atta cords you wil need coples for credentialing and other purposes. This completed renewal form With attaghmea(s must bo retaraed le the erzen envelope af east 4 weeks before your renewal date, ' Please review carefully the following information for accuracy and completeness. Make any corrections or alterations as required. All questions must be answered or your renewal will be delayed. 1. Current Status: Active Registration No,: 210838 Renewal Date: 12/02/2003 {you wantto change your curent status, please check one ofthe following boxes to indleae your new status: (Check oaly one) Clactive CE) Retiring (see instructions) EC] tsactive (ee instructions) | (1 De not wish to renew ‘Please make corrections (print) 2, Other Neme(s),ifany, under which you were license eee Other Nemes) L] Name Change (enter name Below) 3. Andea B Arena Malling Adarees ) Home Address: Home Phone: Business Phone: (617)983.1793 PLEASE NOTE: Oniyangsaivan can bU3 FO.box. The maling address cannot be &P.0, Box. = 4 a) Date of Bint bSex —F | 7. Curent Americ Board of Medial Specalies Caifcation Seated oss Code: FP Cae ‘Drug License Numbers, if any ‘i 5. a) Name of Medial School: 8) Federal (DEA): = Univesity of New York Downsats Medial Cx] ese (DEA. Year Graded y99g«) Degee perenne gona 0) 9.) Ota ses where yee now ened price (Abbe) 6. Specs Codes (Se Tale) pagan ae te Wesk aes Whee yo wee prvi Tacs (ABgy oss Wer a, Sates Whee you were previous (Abr) s SiGe ck gee ate eee 10, Lista arent heath care facie at which you are flied or have comple the ccdentaling proces for he provision of paca care (Suppl the codes fom Table and paca chek mark nxt fo those heh cate alies wher youbave nite seca Nexto cach city, write the approsinale pacenage of patient care hours tha you provide neh Bctiy) Ne cnet Fuclty Cer ©3O/ Mary) GS % racy Coder % Facliy Code: = Pay ose PRINT YOUR LAST NAME 11, My media malpractice insurance covered by J Inuance Carer Ltr of Cet Insurer's name. (Required) Alternatively indicate as follo ‘because Tam: Check One: C] Ne otherwise exempt Please expls 12, What is your principal work: {or the provision of patient care 13, Care of patients in Massachusets 22 adjudicated, or otherwise resolve, . Has any lawsuit, other than a medi ‘or your professional conduct in the ucexst women: 240538 * Policy dates: From: | /2Z3/O3ro, 1 23/04 ‘am registering with Active status but am not covered by medical malprectice insurance involved in diectindrect patient care in Massuchusess [-] A goverment employee. exemption: (Seo Table) J. S_Iryou are affiliated with a healdnare facility or redentisted ‘must complete question #10 on page I and list your affiliations. fe instruction booklet), Dipatenteare Lx F ptt ny nupadonrcare DI] teenie 1) Averige weekly hou involed 2) Whats th apprornatperestage of your patente nus in primary exe? |OO % .T A ~ QUEST] REI therwise resolved? ae oun ced than cl oan Hae you ben hase iho sry everett bahar ly, gp pain opted yor enone Hi or pee pnts dpe ‘etrcted by, or surendored to any’ ). Have you withdrawn an applicator ia any professional liability insarince provider restricted, limited, erminated, imposed a surcharge or co-payment, or placed any conditio related to professional competency or conduct on your coverage, or have you voluntarily restricted, limited o rofessional lability insurance p ‘SME CERTIFICATION: Have Co CME Waiver. CME waiver SMEEXEMPTION: Check one ee Instructions for CME waiver Pursuant to G.L. ¢. 112, See L and the punishment fr failure Pursuant to G.L c. 112, Se. 2 ‘amount. Pursuant to G.L. c. 62C, 494, ‘Massachusets state tx retas G.L.¢. 2E; and withholding: T hereby certify under the penalties Signature: a aes ee Owners” ow: 118,23 ON ONLY TO IEE INSTRUCTIONS) ‘Has any medical malprectice claim been made against you that has not = whethes or nota lawsuit was filed in elation to the clin? ical malpractice claim that bas been made against you been settled, ‘OF nota lawsuit was fled in elation tothe claim? I malpractice suit, which is elated to your competency to practice medicine, actce of medicine, been fled egainst you or been setled, adjudicated or inlined for any violation of laws, rules, by-laws or standards of practice of nse or prescribe controlled substances boon suspended, revoked, deniod, sate of federal agency? fora medical iene or been denied a medical cence for ny reson? terminated your insurance coverage in response an nquey by @ ide? completed your CME requirements preceding your renewal date? [S{'Yes [] No Pr rns be submited at est 30 days pir to license expiration dt C1 Inactive status O Residency/#ellowship training (See instructions). lor exempons, Do nor submit documentation of your CMEs with application, hLundastnd my oliptons opr suse ornget of hiten wer QL 119, 651A comply Twill no charge fo or ells om a Medicare beneficiary mre thn the Medicare fe echedle certify thet I have complied with al laws of the Commonwealth related to the filing of jand payment ofall Massachusetts ste taxes; rpoting of employees and contractors under emting child support pursuant to G.L, c, 119A, (See instuctions), Massachusetts Physician Renewal Application Physician Name: Andrea E Arena License No: 210558 PARTA 1) Current Status: Active Renewal Due Date: 11/04/2005 Birth Date: ‘you want to change your current status, please check one ofthe following boxes to indicate your new stats: (Check only one). (See Renewal Instructions, page 3.) Bi active OF Retiring 1 inactive Do not wish to renew = infirm your addresses and make changes, necessary, You are fedizije within 30 days of any change of address. Home and sh y 2) Addresses & Contact Information. Please required 0 notify the Board of Registrat Business addresses CANNOT be a Post 2a) MAILING ADDRESS. —§/Z/ ‘lease make corrections (print) nied ome Telephone : ie DeUletheeoctorer aes Home adress cannot be «Post Office Box 2) BUSINESS ADDRESS os 065 Gumouwealth Ave 1353 Dorchester Ave tte (OG Conemna woe Dorchester, MA 02122 Ciyrtown:_Bostoh sate_MA Zip: 0LZ]S__ Counvy: =a) SA Business Telephone GS GIG [LCO Business adress cannot bea Post Office Box Phone: (617)288-3230 atthe here ochonge hoes 3) E-mail Address: 4) Fax Number: 5) Specialties (See Renewal Insiructions, page) Delete? | _ Additional specialties: Family Practice a o a 6) Current American Board of Medical Specialties (ABMS) oF American Osteopa (See enclosed instructions and Renewal Instructions, page 4.) ie Association (AOA) Information. List Certifying Board(@) below: Update General Certificates and Subspecialty Certificates below. Please add additional Certifications as required. Board Name ABMS or AOA| CertificateSubspecialty Correct? Delete? Family Medicine ‘ABMS — | Family Practice ommeGl Ean cae cc Page 1 of 7 Massachusetts Physician Renewal Application Physician Name: Andrea E Arena License No 210538 (Gee Renewal Insiuctions, page 4) 17) Drug License Numbers, if any Please mole corrections as necessary 8) Other states where you are now licensed to practice (Abbr) 8) Massachusets: Line ine eee ee oe ) Federal (DEA): ') States where you were previously Heensed (Abbr) ©) Federal (DEA) XS: by '9) What is your principal work setting? See Renewal Instructions, page 4.) Principal Work Setting: Clinic Change to: Please enter the approximate muber of work hous at your principal work setting: LOZMM@ATH, 410) List all current healthcare facilities where you are affliated or have completed the credentialing procéss for the provision of patient care. (Supply the name ofthe health care facility from Reference Table $ on Page 16 of the Instruction booklet). Next to cach facility, write your staff eategory at that facility (Admitting, Active, Courtesy, Associate or Consulting) and the approximate number of hours of patient care that you provide at that fac {Include any affitiations with on-line prescribing services or companies, Please provide all information for ad {aclities on a separate sheet, if necessary. jonat No Affiiations Please enter the aparaximate number of work hour for each Health Care Paci below: Tealth Care Fucity (See Renewal Insracions, page 4) qe Se esa Boston Medical Center Vv £16 ofo/oololo]o] £ 11) Care of patients in Massachusetts (See Renewal Instructions, page 4) Average weekly hours involved in: a) inpatient care _!_thrswk Change to: __(D hrs/wk )oupatient care 22 hrsiwk Change to: _ 2 hrs/wk 12) Medical Liability Insurance Information (See Renewal niructions, page 5) “My medical ibility insurance is provided through: (check one) (1 insurance Carrier (complete below) ‘Current Insurance Carrer: Promutul Insurance Change to: Policy dates: From (required) 1 Letter of Credit subject to Board approval (atact a copy) 2 am registering with Active status but Iam not required fo have medica abil Check one: C1 Not involved with dre! or indirect patient care in Massachusetts 4B Govermnet Employee Federal Tort Citims Act (FTCA) 1 Otierise exempt (Please explain Page 2 of7 a Massachusetts Physician Renewal Application Physician Name: Andrea E Arena License No: 210538 13)Do you perform any surgery in your office? (See Renewal Instructions, page 5) Yes L] No Yes, please complete Form PCA-O "Office Based Surgery” license renewal/application, to the day you sign this renewal application, inclusive. See Renewal Instr Renewal Instructions for additional information and definitions. ALL questions inthis section mast be answered, In questions 14-21, the phrase "time period” refers to the following: all time from the day you signed your last ‘You must check ether YES or NO to each question. Provide details on Form R if you answer “YES” to any questions. Refer to uctions page 5) YES NO 44) CLAIMS MADE 18) New: Has any medicel malpractice claim been made aginst you during this time perio, whether or nota lawsuit was filed on that claim’? Pending: Are there any unresolved malpractice claims against you today, any claims that have not been finally seed or finally adjudicated? 15) CLAIMS PAID Has any medical malpractice claim against you (whether or nota lawsuit was filed on that claim) been resolved, settled, or adjudicated during this time period?) 16) OTHER CIVIL LAWSUITS {Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 8) New: Have there been any lawsuits, other than medical malpractice claims, been filed agsinst you uring tis time period? 1) Resolved: Have yon resolved, sot or adjudicated any laweuits, other than medical malpractice claims, during this time period? 17) CRIMINAL CHARGES 4) Have you been charged with any criminal offense during this ime period? 'b) Are there any criminal charges pending against you today? ©) Heve any criminal offenses/harges against you besn resolved during this time period? 18) Have you been charged with or disciplined for any violation of laws, rules, by-laws or standards of pracice cof any governenta authority, heath care facility, group practice or professional socity or asociaton? 19) Has your privilege 10 possess, dispense or prescribe controlled substances been suspended, revoked, ‘denied, restricted by, orsurendered to any state or federal agency? 20) Have you wihravm an application fora medical license, allowed a license application to become obsolete corhave you been denied a medical license for any reason? "Z) Has any medical lability insurance carrer reseed, limited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency or conduct on your coverage, oF hhave you voluntarily restricted, limited or terminated your insurance coverage in response to an inguiry by a medica ability insurance career? 8 i) CME CERTIFICATION: 8) Have you completed your CME requirements preceding your renewal date? E2Yes C] No 1) fo, are you requesting a CME waiver? 1D Check to request CME Waiver. A CME waiver request form must be submited atleast 30 days prior to ‘your license expiration date. (See Renewal Instructions, page 8) ©) Ifyou are exempt from CME requirements, check reason for exemption. (See Renewal Instructions, page 8.) (CME EXEMPTION: (check one) [1 Inactive Status Residency/Fellowship training Page 3 0f7 Massachusetts Physician Renewal Application Physician Name: Andrea E Arena License Nos 210538 PHYSICIAN PROFILE T_Thave reviewed my Physician Profile t profiles massmedboardorg and confirm tha the information f accurate. 1 thave reviewed my Physician Profile and attached a copy ofthe Profile with comectons. 11 My stam nsetive and} donot havea Physician Profile. (See Renewal Irsracion, page 10) cHIFICATH 2) comity that have complied with my obligations to report abuse or neglect of shen pusuat & O.L.€. 119, 86. SUA, snd J understand dhe punishment for failure 1 comply. 2)1 certy that Ihave complied with my obligations to report abuse or neglect of disabled persons pursuant to GL. . 19C, se. 10, and ] understand the punishment for failure to comply. +3) certify that Ihave complied with my obligations to report sbuse, neglect or finan Pursuant to G.L. .19A, sec. 15, and I understand the punishment for failure to comply. exploitation of elderly persons 4) certify that 1 have complied with my obligations to report the treatment of wounds, burs and other injuries pursuant to GL.c. 112, see. 124, '5) certify that Ihave complied with my obligations to report the treatment of vet G.Le. 112, see. 124 12. of rpe or sexual assault pursuant to ©) I certify that I have complied with my obligations to report a physician tothe Board of Medicine, pursuant to G.L.c. 112, ‘see. $F. when lave a reasonable basis to elieve that person violated any provisions of G.L. e112, ceo. $ or ony Bourd regulation, 1) [certify that Ihave complied my obligations related to charging and collecting fees Srom Medicare beneficiaries in accordance withthe Medicare fee schedole, and I uderstand my obligations under G.L.c.112,see.2. £8) certify that Ihave complied sith my obligations to filo Massachusetts tax retums and to pay Massachusetts taxes, and Y ‘understand tha, pursuant to G.L. . 62C, see. 49A, my license shall nt be isued or renewed unless I make these

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