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Commonwealth of Massachusetts 560 Harrison Avenue, Suite #G-4, Boston,

< irofiafii$m - Board Registration in Medicine

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MA

02118 (617) 65+9E10 - www.msssmedboard.org

FULL LIC ENSE APP-LJCATION

Aootication Fce:Please
en-c.lpse a check or monev order in the amount of $600.00 made payable to 8re Comrnonwealth Massachuseus. The application fee is non-refundable.

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I-cgrl Naqre (do not use nicknames or initials, unless lhey

ofyour legal name)

Spurrell, Timothy

Patrick

Last Name (type or print

clearly)

First
otherdesree

Middle

Suffix (Jr-, etc.)

dv.o.tl p.o.E Ph.D n

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Female

Other Name(s) Used - List any other name(s) you have used which may appear on your identifring dccuments, such as medical education and examination records. lfnot applicable,-check hete

Entire Last Name (type or print

clearly)

First
Social Security Nrmrber:

Middle

Suffix (Jr, etc.)

Date of

Birth:
Month Day Year CitY

Place

ofBirth: Lowell, MA

StatelProvincdTerritory
Number and Street

Country if not USA

Home Address:

clty
Business Address:

State/ProvinceJTerritory
215Toll Gate Road, #306
Number and Stcet

Zip (or postal) Code

Wanrvick,

RI

02886

City Business Telephonc

E-mail Address: Prefened Mailing Address:

State/Provincey'Tenitory

Zip (or postal) Code

dqfi392q99_-xt.
n
Busine.ss

Home

Telephone:

Address f,

Home Address

Are you applying for licensure through FCVS? (See ins[uctions page I

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PRTNTNAME:

Timothy Spurrell, MD

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PAGE 2OF4

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Pre-medical School

Facility: Universitv of

Street: 883 Broadwav Street, Room

Facility: Radford University

Massac

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City:

Degree: N/A
Loweil

Fnrm
i9

To

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State:
MA
"F

Street

115 Martin Hall. PO Box

69Ot

u City: naOtorO
Degree: t MD Degree: MrJ

/_/83 JUJ_85. - StatFG

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Medical School Facility: University of Connectlcut

From

Street: 263 Farmington Avenue,

Facility:
Street: Date of medical school

MC1827 City: Farmington _

Degrec:

_08-!n_!_92- i5 /23 / 99

State:

cr

tt

t/

Ctty:

graduation: 05

I 23

I 1996

Note: u.s. graduates must include duration of medical education tonger than four (4) years, and for any breaks in mcdical" education. Intemational graduates must provide a uritten explanation for the duration of medical education longer than six (6) years and any breaks in medical education.
Postsraduate Educstion :

#ill"*pmli*

fo.;;

List all postgraduate training in chronological order from medical school to the present. Include the name and address of the facility, your position, e.g. PGY 1, 2, felloq etc. and dates of affiliation. You must account for all periods of training or postgraduate work tom the time you graduated fiom medical school.

From
lnf,.nf" Facility'. Wo"t"n "nd Street i01 Dudlev Street

To

H*p

porition:Rffi
City:
providence

_o6J_4!_w_

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Facility:
Sbeet:

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State: State:

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JJ

Facility:
Street:

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-wwwmrssmcdboard.org

r,UI,L LICENSE APPLICATION

$+ticrtledgPlcaq9 cnclosei cleck or mop:c.)Lqrder
Massrchusetts. The application fee is non-refimdablc.
$)

iT.the amourrt of $6fi).00 made payable to thc Commonwealth

of

Chccl Ooc:

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U.srcanaaianGraduate

Intcmational Graduate

Lcg,d Nemc (do not us nicknanres or initials, unless they are part of your legal name)

Spunell, Timothy Patrick

LastNaure

(t'"e
otherdegrcc

drur.o.tl D.o.fl prr.u L]

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fi

Fenale

ot!9r !{rF#s}-qsd - List:ny. other name(s) you hy^" gt"a whicb may gpear on your idenriging documenrs, srch as medical education and examination records. rf not applicable, check heri
Entke LastNamc (type orprint crcarty)

First

Suffix (Jr- fc.)

Date

ofBirth:

lfi;ilWG-

Social Security Nunber:

Coutryif notUSA
Home Ad&ess: Number anA Stre*

City
Business Ad&ss: 21

tate/Prov ince/Tcnitory

Zip (or postal) Code

5 Toll Gate
Numbsr and Stcet

Warcick, R|02886
City
StatclProvince/Territory

Zip (orpostal) Code

Busirc$
Telephone:

@_f239-2000-.*t.
Address:

Home Telephonc:

E-nail Address:
Preferred Mailing

Busincss Address

tr

HomcAddrrss

Are you applying for liccnsure rhrough

Fcvs?

(Sec instructions pags

il) D yes

El

No

t\)

PRrNr NAME:

Timothy Spurrell,. MD

PAGE 3 OF,$

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(,1

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Hosoital Affiliations and Bmnlovment

List hospital appoinknents, in chronoloeical order. where you had active staff privileges. lnclude the name and address ofthe facility, your position and dates of affiliation. Also include periods of inemployment or employment outside of medicine. Attach a separate sheet of paper if necessary. From To

tri

Street
Street

Facility:

women and lnfanfs Hospitat of Rhode lslan<t

pqsilienrlhff Privileges
ity:

Proffiice-

061 /0A St"t.Iir

State: Rl

Prqseni

Facility: Women's Care

390 Toll9_ate

Road

position:_?try19!gq!_ Ciry; Warwick

r9t-41 08/
State:
Rt

0'!

Facility:_ Rhode lsland Hospital

Steet'
Sheet
l.

5g3EddyStreet

City: Providence
pOrl1ior,- Physician/Partner

Position: Staff

Privileges l9l l0O PregentT 0U_/91_ ELesSqt_

State: Rl

Facility: Jgl!ng&14&rnen
2't5 Toll Gate Road. #306

City:__l{eru4g!

List other states (abbreviations) where you are curently or haye

e:ver been

licensed: Rl
No

2. Are you certified by the American Board of Medical Speciarties?

J,

gl vo tr

List Board Certification(s1. American Board of Obstetrics & Gynecology

Certificationdate: 10
Certification

/03

date: I

4.

List your practice specialt(ies) OVGYN

5. Have you attached an up-to.date copy of your curriculurn vitae? 6. Reason for requesting a Massachusetts medical license:
8. Name ofFacility:

6 to tr

No

9. Address:
10. Anticipated starting date in Massachusetrs:

City:

Aflidrvit of Applicant
I, the undersigned applicant, hereby ceftiry thal all information included in this apptication for licensure constitutes a true statment made q4der the penalties of perjury.

Signature of Applicant

__UJLXL Month Day

Year (Continued on page 4)

PRrNr NAME:

Timothy Spunell. MD

PAGE 3 OF,1

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Hosnitsl Afiiliations gnd Employment

List hospital apointments, in cbrongloeic+l order. where you had active staffprivileges. Include the name ad&ess of the facility, your position and dates of affilidion. Also include pedods of unemployment or employment outside of medicine. Attach a separate sheet of pper if necessary.

ad

ti

From
Fasility:

To

Strect 101 Dudley Street

Women end lnfanfs Hospitalglshode lsland Position: Statr

Privi$e

City:Providsnce

!9t_t9t lgryt-_ State: Rl

FaciliSr: .Women's Care Street 390 TollGate Road

Pcition: Phyisican. City: Wanick

W_tq !8/_r i1 Statc: Rl

9q/-/!g- P*EggSate:
Rl

Facility: Rhde lsland Hospital

Steet

593 Eddv Street

City:

position:_9tafi Prlylgges ProviOence

Facility : Caring furWomen

Positionrllf-t"ry-

Steet:

215 TollGate Road. #306

_g8r_/91_ e19@rr_statq

City:_Warcick

Rl

1. List other states (abbrcviations) where you ax currenfly or have ever been

licmsed:

Rl d*e:10
,!.

2. Areyoucenifiedby the AmericanBoardofMedical Specialrie!:?

il

Yes

fl

No

3. LisrBoard certification(s),

Attt"ti*" B*td

"f

obtneti*

&

Gyt

certification Certification

t03

dats_i

4: List your pracdicc speciat(ieslqq/GI!

5.

Haveyouattachcdanup-lodatecopyofyourcuriculumvitae?

6. ReasonforrequestingaMassachusetbmedicallicense:

-Jb 7F f.\t'D- -lAY f Rr'-T1AE

fr V.t I

No

8. Narne ofFacility: 9. Address:

10. Anticipated starting date in Massachusefisz

2?!.

tzb

.City:

Afridavitof Applkant
I, theundersigned applicaut, hereby ccrtiry that all information includd intris application forlicensure constitutes a tnre statcment made under the penalties of perjury.

L-

Month

r_Io L26og
Day
Year (Continuedon

pge4)

lil

!:)

PRINTNAME.

TiMOthY SPUTTEII, MD

PAGE 2 OF4

trj pt

Pre-medicrl ScJool Faciliry: Univeniwof Massaefrusets,

Street
Street:

883 Broaduyay Street, Room

104

Lpwdl

Degree:

NIA

City:

Lowell

To From -QgUgL -$UJg State: MA

l(\

Facility: RadtordllqleaQ
115 Martiq_Hall. PO Box

69!4

Degree:

Bs

City:

ix/-lg!- JUJ-W
State: vn

Radford

MedicrlSchool
Facitrty: University of

Streec 263 Farminqton Avnue,

Facility:

conngcticut .

MC1827 City: FarmirulonDegree:

Degrec

.MD ff-r-

-qg-rl-rj! Sbte: cr

Strwt:

clty:

IJ-JJ State:
96
Ycry

Note: U.S. graduares must include a wrinen explanadon forthe duraion ofmedical education longer *h*n four (4) yeargandforanybreaksinmedicaleducation hterndioualgrduatesmustprovideawitenelplanationforthe duration of medical education longer tlnn six (O years and any brcaks in medical education.
Postgrrduate Educrtion : List all postgaduate taining in chloqolpgical order from medical school to the present Inclu& fte name and ad&css of&e facility, your positioo, e4; PGY l, 2, felloq etc. and darcs of affiliation You must account for all ptiods of taining or postgadude work fiom the time you gra*ureA Aom medical sohool.

Dateofmedicalschoolgraduation: 05 .f,hrh

I ZF I
Dry

From
Facility:Wornenand lnfantb Hogpitalof Rhode lsland

T_g

Steet {ol
Facility: Steet: Facility:

Dudtev

Sfnel

fosition:Rffi1", _o.oU!g_ !n U!9 City: Pro/'dencp . _.. Stafp: Rl

Position:llll
Crty:

Stwt:
Facility:
Street:

Position:_
City:
Position:

sble:

_JJ_

City:
Position-

ttlt
State:

Fairlity:
Streeu

tttt

City:

F'ULL LICENSE APPLICATION

NATIONAI. IFOVIDER ID&\TIFIER fIIPI}

PAGE 4of4

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The prirmry purpose of the NPI is to uniqueiy identify health care pmviders as'tealth carc providen" in HIPAA staodu'd transactions. Tbc NPI will rcplace all other ideatifen assigrcd to health care providen such as those assigned by health plans, govcrnment prograrm and heahh care prrrchasets for purposes ofcotductiog these br.rsiness traosactions. Under the final HIPAA NPI Ru1e, all individual and organization covercd providers rvill be rcquired to obtain an NPI by May

(l

Cr

t(t

23,2&1-

Iu order for lour

Ootion

Sll

license rpplication to be comnlete. t'ou must lakc one of the followine rctlon$:

l:

SupplytheBoardofRegisnationinldedicinewithyourvalidNPl. YoucanapplyforanNPldirectlybyusingthe

NPPES web site at www.NPPFS.gnrs.hhs.gov. Optign-2: Certify you have pcrsonally applied for yow NPI and you bave not received it yet. You nust rnti$ the Board once you havq received your NPI Number. Please complete the NPI foau at the Boord's web site at wwll8lssmedboard.org. 9ptior 3: Certi$ another autborized iastitution has rpplied for an NPI on your bcbalf and you have Dot rceived it yet (srypty instituioa s name). You oust noti$ the Board orrce you bave reccivcd your NPI Nrrmber. Ootion 4. Authorize the Board ofRegistration loMedicine to apply for anNPl on your behalf.

u u

I havepersonally apptied for

anMI.
(foltow iastrucrions tbr Option 3)

tr

I have applied for

aa

NPI using a third party (ealer name):

By checking this option aad signing the bottorn of this page, I heleby aurborize tbe Boord to apply for an NPt on my bebalf.

HIPAA TAXONOUYCODES
PleasE proride th9 HIP{A taxonomy (ryecialty) codcs. (See p4ge 12 of FuIl Licensc Application Insqncrions)- In addition to provi{ing the laxor]omy code, please iodicate your specialty in thc space provided (Taxonomy Description). The ptimary providertaxononty code is required if you authorize BORIM to apply tbr an NPI on your behalf.

Taxonomv (Soecialw) Code Priraary Provider Taxolomy: Pr,oriiler Taxonotoy:

faxonomv De,scriotion (Print)

Obstetri cg & .9vfreqglogy

Provi&r Taxonony:

\?I

REo UIRED

llq[o&yu{Tloli

In au ongoing efliort to improve tbe guality of the information we collecg please review the following infonnarion and make conections as necesiary. ?kese note: This information is required if you authorize BORIM to appty for an NPI oolour behalf,
Social Securitv Number State of Birrh (if.ll-S):

M.A

Couatry of Birth Femate

(if outsiile

rhe US):

Cen&c

ua.

fl

18

Snlercing Statut,

makcs ay falsc, fictitious or fraudulcot statcmcils or rcprsntatiooq or makcs my tfusc or dosumcnt k1owing thc samo io cortain any false, fictitious or Aaudulent ststmgt or entry. Iadividual offecdcrs ue subjectto fnes of ug to f250000-and imprisomcnt for up to live years. grganizarions are subject to fines ofup to Si00,000. lS U.S.C.3j?l(d) also aurtorizes fincs ofup to twice the the ofiender if it is grcaEr frau ttc arnount specifrcally authorizcd 6y the

agacy of tte Unitd Slsls lo{wlngly and willfully falsifics, conccals or covts up by any tric\ schcnc ot dcvicc r nac.ia mcq on -wririog

Pca{{f .f9r FtHSine lnfornt$4 on thf Ntlbql.tfovidcr Idcarilicr Aooticrrieru.s.c. l00l ausorizes oryioq pcnaluis agairs

dcpsrfrflt or

Date

LJ>169 v

PLEASE MAXE A COPY OF ALL PAGES OT YOUR FI'LL LICENSE APPLICATION ANI} AI,L ATTACHMENTS EEFORE MAILING YoIrR REcoRIrs' FoR CRDDENTIALING AND OTEER PITRPOSES-

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Massachusetts Applicetion for Licensure

Timothy Spurrell, MI) Addendum to Hospitel Alliliations & Employment:

FacilitvName & Address Kent CountyMemorial Hoqpital 455 Toll Gate Road Warcich RI 02886
Position StaffPrivilqges
Dates

r;n

g)

ofAfEliation
rs

0812W1- Present

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ttl

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198?-1989 Mental

Health Worker, fnlrl-"*:itorpital, Behnont, MA Counseled hospitalized patients as part of a multidisciplinary team.

{a

RESEARCH HGERIENCE:

s
200r
Frishman G.N., Spurrell T.P., Heber W.W. Folic Acidpreconceptian Ioowledge; use by inferiite women, Journal of Reproductive Medicine. 2001 46 (12): 1025-30. Research Project University of Connecticut School of Medicine, Farmington, CT. Lrsoctal support a predictorfor

1993'1994

medication use in the nursing home? Awarded $10,000 grant from the American Federation of Aging Research to conduct Jtuay. 1989-199 Research Assistant, Harvard Medical School, The Cambridge Hospital Cambridge, MA. Adapted Luborsky's Relationship Anecdote paradigm Model to Psychotherapy transcripts to assess patterns of selfiefeating behavior in persons at high risk for HIViAIDS. 1988-1989 Research Assistant, Harvard Graduate school of Education, lvIA- Researched, rgviewed anil critiqued the philosophical, empirical and clinical papers regarding the development and undersandi"g oTemotional ambivalence.

TEACHING EXPERIENCE:
2000- present Voluntary Teaching Faculty, Women and lnfants Hospital ofRhode Island 1992-L996 Member, Clinicat Medicine Committee, University of-Connecticut School

of Medicine, Farrningto4 CT.

1992'1996

Developed new cuniculum emphasizing primary prevention and wellness. Authored syllabi and led seminars for first year medical students. Seminar Instructor, University of Connecticut School of Medicine, Farmington, CT. Led seminars for health center staffand employees in The areas of sexual harassment and diversity haining.

HONORS, AWARDS A}.ID ACTTVITIES:

2001 2001

Yoluntary Faculty Teaching Award, Brown university Dean's Teaching Excellence A*ar4, Brown university 1999-present Member, OB/GYhl Resident Tajk Force 1996-1998 Medical Snrdent Teaching Award Merck scholar, university of connecticut school of Medicine 1992-1996 Peer counseloi university of connecticut School of Medicine

1996

OTIIER EMPLOYMENT:

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CURRICULUMVITAE

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TIMOTI{Y P. SPURRELL, M.D., M.Ed,
LA

PERSONAL DATA:
Residence:
Business: Caring For Women 166 Toll GateRoad

E-Mail:

Wanviclq zu 02886 Birth Date:

EDUCATION:

M.D.

university of connecticut school of Medicine

1996 Farrrington"

cr

M. Ed. Harvard Graduate School of Education, 1990, Cambridge, MA

Counseling Psychology

B.S.

Radford University, Radford, VA Accounting

CLINICAL DGERIENCE: 8/01-present caring For

2000-2001 women's care

l99G2a0B

staffPsychotherapisq Millord Mental Health clinic, Milford, Engagrcd in weekly individual and group therapy with adults suffering from both acute and chronic psychiatric conditions. 1988-1990 Mental Health Worker, The Cambridge Hospital, Psychiafric Emergency Department Cambridge, lvIA Served as the psychiatic staff to the emergency room to provide evaluation and disposition forpatients presenting with acute psychiatic

l99a-l992

166 Totl Gate Road warwick, RI 02gg6 390 Toll Gate Road warwick, RI 02886 Resident, women & Infants Hospital, Department of oB/GyN, Providence, RI

women

cr

1987-1989

issues. Case Manager/Counselor, North Suffolk Mental Health Association

Chelseq MA Supervised mentally retarded/emotionally disturbed adults in a residential heatment facility. Developed and impleme,nted individual service plans.

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PROFES SIONAL MEMBERSHIPS

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2000-present American College of Obstehic-s an{Gynecology Fellow

REFERENCES: Donald R. Coustarq M.D. Obstetrics and Gynecologist in Chief Professorand Chairman
Gary Frishman,

M.D. M.D.

Associate Professor of Obstetics and Gynecology Reproductive Endocrinolo gy Assistant Professor of Obstebics and Gynecology General Obstetrics and Gynecology

Lori Boardman,

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SUPPLEMENT F'ORIYI
pRTNTNAME:

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Timothy Spurrell, MD

DATE:

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07

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IMPORTANT,NOTE: If you rnswer'yei' to rny of thcsc qucstions, you must provide the edditkmal informstion on pages 4.10,

ouEsrroNs
l. 2. 3. 4. 5.
Since your enrollment in collegg have you been subject to any disciplinary action (see defnition) d an academic institution?

YF$

No

Have yor cver been terminated or grantcd a leave ofabsence Uy a meOicat scbool or medical pcst-gradnate tainingprogram orhaveyou everwithdrawn from amedical school or medical posQraduate taining program or had to rpat a year of postgraduale taining? Have yor ever applied for liceirsure or to sit for m e:ranrination or hken an exarnfuration under a different name? If so, previous Sincr your emollment in college, have you been denied the privilege of taking or finishing an e:nination or been accused ofcheating and/or improper conduct during an examination? Have you ever failed any of the following e:minations: FLD(, any State Boad endnation" any part of the National Boad$ any Stp ofthe USMLE, NBOME, or havc you failed to gain certification from fie Ndioml Board of Medrkzl Elrminers, any othcr certification body or any foreign licensing or certifietion body? Have you ever, for any rasoq ben dtded amedical licensg whether full, limitrs4 tmptrary, or have you withdrawn an applic*ion formedical licensure? Have you ever voluntarily surendered a license to practice medicine or any healing an? Have you evcr, for any rcason, lost Ameriia Bord of Mcdical Spcialty or been deniod required recertificatiol by oae or mor speciatty boards?

GA. 6-8.
7.

Are any formal disciplinary cbarges pending againstyolt or do you have knowledge of any pending investigation into your pmfcssional competence or conductby any governmental authority, health care facility, group practice orprofessional medical socity or association (intrnalional, nationaf state or localp (Se definition).

8-8.

Has any disciplinary action ever bce,n laken agrrinst y6a1 for violation of lawq nrles, by-laws, or sandards ofpractice S any govemmental aueorify, healthcare facility, group or professionat medical sociefy or association ( natioaal, state or local)?

Applicant's Signanne:

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9-8.
ltraveyou ever voluntarily relinquished any medical staffmeinbenhip?
Has your rnedical staffmembcrship, medical privileges or medical staff shtus at any hospital been limitd suspended, revoked" nct renewed or subject to probationary conditions or has processing toward any ofthose ends bn instituted or recomrnended by a medical stafrcommittee orgoverning board?

N(}

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Have you ever been denied medical staffmerrbership, or advancement in nedical saff stafi$, or has such denial been recommended by a sanding medical staffcommifiee or governing body?
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cs

appoirfirot?
10. 11.

Have you everbeen charged with any crimiaal offense', otherthan

minortaf,fic offense?

IIas your privilege to possss, dispense or prescribe confolled substances ever been suspended revokedo dnied, resticted or sun'endered, or have you ever bercn called before or wamed by any state or otler jrrisdiction inchading a federal agncy regarding zuch privileges?
Has any professional liability insrrance provider ever restictd linited, terminate4 imposed a sr:rcharge or co-paymnt, or placd any condition relded to gofessional competency or conduct on your coverag or have you ever voluntarily reshicted, limited or terminatedyourinsurance coverage inresponse to any inquiry by aprofessional liability insurance providei?

t2.

13.

flave you ever been the subject ofany suspension or probation proccedings institgted Btue Cross or Blue Shield Medicare Medicai4 or any otrer medicat Reimburse,ment plan; or have you ever beea resticted from receiving payments ftom my Blue Cross or Biln"

Shiel{ Medicare, Medieid (any staE), orttird parfy progans?

14l5-A. l5-8.

Have you ever had an applicaticn for membership as a particiEating provider reictd by aty HMO/?POIIPA or o&er prepaid health care plan or your onteact as a partiiipeting provider termincted by any HMO/PFO/IPA or otrerprepaid ptan?

In tlre past ten

(l!)
a

whetherornot

years, has any medical malpractice claim bcen made against lan'zuit was filed in relation to the claim?

yorl

related to your competency to practice medicing or yurr professional con&rct in the practice of medicine, been filed againstyou or has such aiuit been settle4 adjudicated otherwise resolved?

In tle pastten (10) years, has any lawsuit, otherthm a mdical malpractice suit, which is

or

Applieertls

,*r"z,ltrOE

l0

tt ffr

)@g
9-A. 9-8.
Have you ever voluntarily relinquished any medical staffmembership?
Has your medical staffrnembership, medical privileges or medical staffstatus at any hospital been limited, suspended" revoked, not renewed or subjectto probationary conditions or has processing toward any ofthose ends been instituted or recommended by a medical stafFcommittee or governing board? Have you ever been denied medical stalf membership, or advancement in medical staff s(atus, or has such denial been recommended by a standing medical staff comrnittce or goveming body?

Na

,f,
f"$

$)

s -J

9-C.

9-D.

Have you ever, for any reason, withdrawn an application for hospital privileges or
appointrnent?

10.

Have you ever been charged with any criminal offense, other than a minor traffic offense? Has your privilege to possess, dispense or prescribe controlled substances ever been suspended revoked, denied, reshicted or surrendered, or have you ever been called before or wamed by at y state or other jurisdiction including a federal agency regarding such

ll.

privileges? 12.
Has any professional liability insurance provider ever restricte4 timited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency or conduct on your coverage or have you ever voluntarily restrioted, limited or terrninated your insurance coverag in response to any inquiry by a professional liability insurance provider? Have you ever been the subject of any suspension or probation proceedings instituted Blue Cross or Blue Shield, Medicare, Medicaid, or any other medical Reimbursement plan; or have you ever been reshicted from receiving p,yments from any Blue Cross or Blue Shield, Medicare, Medicaid (any state), or third pany progrants?
as a participating provider rejected by any HMOIPPO/IPA or other prcpaid health care plan or your contact as a participating provider terminated by any HMO/PPO/IPA or other prepaid plan?

13.

14. l5-A.

ilave you ever had an applioation for membership

In the past tcn (10) years, has any medical malpractice claim beeri made against yot5 whether or not a lawsuit was filed in relation to the claim?
the past ten (10) years, has any lawsuit, other lhan a medical malpractice suit, which is rclated to your competency to practice medicine, or your professional conduct in the practice ofrnedicine, been filed against you or has such a suit been settled, adjudicated or otherwise resolved?

l5-B. --'In

Applicant's Signature:

""*{o,&pb

Massachusetts Physician Renewal Application

Phydcian Name: Timothy P Spurrell, MJ).
(See Renewal Instt'uetions, page 4.)

Licenee

No.:

o
N
UJ

736470

7) Drug Llcense

Numbers

Please make correcTions as necessctry

Corrections:

S1

Otler
RI

states where you are

lg;g licensed to practice

o o
tJ)

a) Massachusetts:

b)Federal (DEA) c) Federal (DEA) XS:

9) States where you were oreviouslv ticensed

t\)

f 0) List all work iites in Massachusettg includirg health care facilities (where you are credentialed), private officeg clinics, nursing homes, etc. For tbe names of the health crre facilities, refer to Reference Table 4 on page l8 of tbe Renewal Instnrction booklet Include any aflilietions witl! Internet-based prescribing services Please ell a if

List the names of all work

(899. above

sites ia Massachusetts and description on page 4.)

Location (City or Town)

Stale

Delcte?

f t-tttrJpn PlQ.arT*oar>
L-tGt N

A oanom

z s- Dlaaru T-r*aotr

l{A
^^A

tr

u00&c,F sTE8.

n n
D

tr

1l) Cere of patients in Massachusetls (See Renaanl

Avcrage wcckly hours involvcd in: a) inpatient

Instructions, page 4.) Change to:

care 0 ht*l*k b) ougatient care 0 hrJwk

(See Renewal

hrs/u&

Cbaogero:

15

hrVu,k

12) Meilical

Llability Insurance Informati,on

ff:x":ffi:ffi;i;;i;t
Current lreurance Carriec

*'*.

5) Mv medicar riab'irv im'a'ce is provided

Instrucrions, page change to:

through:

Polirydares:
Type

r-- L[rO9

trlr-Lf
with tail coverage

0
il

ofPolicy: {"r^^"rnade

O.cn rorce Policy

{Enclose a copy of lhe certificate of insurence or the face sbeet)

n Letter of Credit subiect to Board epproval (Aaoch a copy)

fI

I am registcring witb Active stttus but I am not required lo have medieal liability insurance
Check

because

aur:

pqE: tr tl tr

Not involved with direct or indirect padenr carc io Massachuscts A Govertrncat Employee under Federal Tort Claims Acr (FTCA) Oherwise exempt (Please

uplain).:
5.1

13) Do you perform any surgery in your Massrchusetts oflice? (See Renewal lnstructions, page

gfVes g1 No

If Yes, please comptete Form PCA'O "Office Based Surge4/ Form on pagc 8.

Massachusetts Physician Renewal Application

Physician Name: Timothy P Spurre[ M.D.
License

No.:

236470

PART A

q
Renewal Ilue

l\)

l)

Current Status: Active

D*e: AUl9f2(tA9

Birth Drte:

o 0
1r)

If youwant to change yotr current

stahrs, please check one

of the following boxes to indicate yorr nary status:

Chyftonly one: 6ee Renewol Instntctions, page3.)

E[

Acdve

tr Retiring

E Inactive

floonotwishrorenew

2) Addressee & Contect Information- Please confirm your addrr*'ses and m.ske changes, if necessary. You are required to noiify tle Btiard of Registration in Medicine within 30 dayr of any change of address..Home and Businers eddresses CANNOT be a Post Oflice Box. Please rnake correclions (print) 2a) MAILING ADDRESS
1363 Narragansett Boulevard .$;

Cranston, RI

02905

F.EiiiUlD . 1 200s

Mailing Address: City/Town:

Slate: CountrSr

ii" ,JAN22 lr
oddressBOafd
Of

Zipr_
Horne Address:

Chec& here to chanse this

Rggistfatign

2b)HOMEADDRESS

in Medicine

Cigflown:

State:

Zip...
Phonq

_.

Comtry

Home Telephone:
Home address cannot be a Post Ofice Box Business Address:

Check herc to changi this ddress

2c) BUSIITESS AIIDRESS

C*ing forWomen
215 Toll GateRos4 #306

City/Town:

State: Countryc

Waiwiclq RI02886

Zjp:
BusiresTelephoae:

"

Phone: (401)?39-2000

LJ.

'E

Check here

to change kis address

Business qddress cannot be a Post Offtce Bax

3) F-mail Addrecr: 4) Fax Nurnber:

Correct your E-mail and Fax Number below:

Ltor ?32 ?${Z

4.)
Delr?

5) Specielties (See Renewal Instructions, page

Llst Addition el Specirltier:

Obsericsarr,itGynecology

tr tr
D

6) Current Arnerican Board of Medicet Specialties (ABMS) or Arnerican Osteopathic Associrtion (AOA) Information. (See enclosed instructions and Renewal Instructions, poge 4-)

Ust Certifying Board(s) below:

Updete Gcneral Certificatee and Subspeclalty Certificatec below- Pleam add additional Certificstionses required. CertilicatelSubspecial ty
Obstetrics and Gynecology
Ilelete?

Name ABMS or AOA Obstedcs & Gynecology ABMS

Board

tr

t]
tr tr

Massachusetts Physician Renewal Application

Phyeician

Name Timothy P Spurrell M.D.

License

No.:

236470
ru

In quesione l4-?.1, the phrase rdme period" refers to the following -- all time from the day you signed your last Iicense Renewal Application to the day you sign this Renewal Application. (See Renewal Instructbns, page 5)
You must check either YES or NO to each question- Provi& details on Form R if you arswu 'YES- to any questions- Refer to Renewal lnstnrctions for additional infonnation and definitions.

ro

qj

YES
14) cr,ArMsMADE
a)

NO
.Jl

oo thal claim, or has anyuredical malpractice claim becn made against you during this time period? (see above).

NEril: Have you received notfication of a claim, whethcr or not a launuit was lilcd

b) PENDING; Are there any unresolved malpractice claims against you today, i-e., any claims tlrat have not been finally settled or finally adjudicated?

l5) cLAIil4s cLosED

Has anymedical malpractice claim against you (whether or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during this tine period?

rq oTrrER crvll, LAwsuITs

Question 16 rcfen to claims or actions related to your conpetarcy to pmctice medicine or your professional conduct in the pq-aclice of mcdicine.
a)

New: Have there been any claims, other than medical malpractice clairm, fled against you during

&is tinr period?

b) Resolrred: Havg you resolved, settled or adjudicated any lawsuits, other than medical malpractice

claims. durine this time period?

1? CRTMINAL CHARGES
a) Have you been charged

wi&

any criminal offcnse during this timeperiod?

b) Havc any criminal offenseJcharges against you been resofued during rhis time period?
c) Arc there anycriminal charges pending against

y* roarf

Q Are any Applicatio,ns for Issuance of Process pcnding against 1ou? rE) nYVESTIGATIONS AI\D DrSCrpLrNARy ACTTONS a) Have pu withdrawn an application 10 any govemnental authority, bealth care facility, group practice, emploler or professional association?
b) Have you ever taken a leave of abseace from
c) Hane

ay

health care facility, group practice or ernpioyer?

been the srbject of an investigation by any govemmental authority, health care facility, group practice, erryloyer or professional associadon?

pu

d) Have you been the subject of a disciplinary action take! by any governmental aurhority, healrh care

facility, grouo practice, employeT.orprofessional

assoctrtiog?

19) Have your privileges lo possss, dispense or prcscribe controlted substances been suspended, revoked, denie4 restricted by, or snrrcndered to any sute or federat agsncy?

._ _

20) Have you withdraum an application for a nredical license, allowed

orhave you been denied a medical license for any rcason?

a license application ro berome obsotere

2r) Has any mcdical liability insurancc carricr rcstrictcd, limited,

tcrminared, imposcd a surclnrge or co-payrncnl, or placed any coodition related to professional corrpetency or conduct on your co\renge, or harrc you voluntarily restricted, limited or terminated ]rour insrrrance coverage in response to an rnqurry by a medical liability insurance carrier?

.TION:
a) Have you completed your

CME rquiremenls preceding your renewal date?

b)

lf

no, are you requesting a CME waiver?

es ENo EY.s E Nu

A CME waiver reqrest form must be submitted rt least 30 days prior to your license.expiration date.
c)

If you

arc exempt from CME requirements. check reason for exemption- (See Reneva! Instru:crtons, page 8.)

CME EXEMPTION: (checkone)

hactive

Status

fl

ResidencylFellowship training

AC_ORD* CERTIFICATE OF LIABILITY INSURANCE

PfODI'CER

BAIE{rrrDorlrm
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Marsh USA lnc. 1166 Avqtrro dlhe Ameticas

NsrflYork,NY 10036

THIS CERTTFICATE IS ISSUED AS A TATTER OF IilFORIIATIOII ONIY AT{D COI{FERS NO RIGI{TS UPO}I TI{E CERTFICATE HOIIER. THIS CERTIFTCATE DOES NOT AMEND, ETTEND OR ALTER ?HE COVERAGE AFFORDED 8Y THE POLICIES BIOW.
II.ISURERS AFFORDING COVERAG E NAIC

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PI.ANNED PAREN1HOOO LEAGUE OF MASSACHUSETTS AN AFFILIATE OF PLANNED PARENTH@D FEDEMTION OF AS'ERICA, INC. 1 055 COMMONWEALTH A\NUE BOSTON, MA 022't$r00'l F{suERB: National Union F}e lnsuranoe Cornpaty 19045

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NOTWTTTISTANDil{G AI.IY REQ|JmEII|ENT, TERM OR CONDMON OF AIT' CO$IRACT OR OTHER OoCUiilEl,lT WITH RESPECI TO WHICH THIS CEFTIF|CATE IS SI'BJECTTO AIL THE TERTTIF, E(CLI'SIONS ANO IiiAY PERTAI.I. TTE IISIT.RAT.ICE AFFORDED BY THE POUCIES DESCRIBED MAY BE ISSII.E:O cotlDlTloNs oF sl.rcH POLCIES. AGGREGATE LMfTs SHOfi{ MAY HAVE BEEN REII-ICED BY P/

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DR NTdOTHY SPTJRRELL IS AN INSURED UNDERTHE ABOVE REFERENCED POUOT.

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Massachusetts Physician Renewal Application

Physician Neme: Timothy P Spurrell, M.D.

O
A)

IjcenseNo.: 23dl70
(d ro

IDART C

CheckOne: T ,** r*rewed D n

PHySICIAN PROFILE

my Physician Profile at http:r?rofiles.m4s$'nedLoar-d-ogg and confirm that the information is acc:uate(Please note that ifyou changed or corrccted your business address, business phone rrumber, practice specialty, board certification and/or hospital affiliations oa your rcnewal application, your Physician Profile will also be updated.)

I have reviewed my Phpician Profile

ad
a

attached a copy of tbe Profile with corrections.

{,See R eneunl

My status is Inactive and I do not have

Phpician Profile.

Instntctions, poge

ll.l
G.L c.
I 19, sec.

.J

CERTIFICATIONS

t) I certify that I have complied with my obligations to rport ahrse or neglect of children pursrant to understand the prmishment for failurc lo comply-

5lA. and I

2) I certify that I have cornplied with ny obligations to report abuse or neglect of disabled penons pursrant to G.L. c. l9C, sec. 10, and I undcnund thcprmidrment for failure to comply.
3) I certifu that I have complied with my obligations to report abuse, neglect or financial exploitation of elderlypersons pur$ant tio G.L. c.19.\ sec. 15, and I undersrand ihe punishment for failurc to corrply.

a) I ccrti$ 0nt I harrc complied with my obligations to rcport ttre trcahent of nouods, burns ard other iajwies pursuant to G.L c- I t2,
sec- l2A-

5) I certi$. tbat I have corrplied with my obligations to rcporr the Eeatment of viclrms of rape or sexual assault pursuant to G.L- c. I12, sec. l2A l/26) I cerriS rhat I have cornptied with my obligarions to reporl a pbysician to tbe Board of Medicine, punilant o G-L c. I 12, sec, 5F, urfien I hane a reasonable basis to blieve fut person violated any provisiore of G.L. c- I 12, sec- 5 or aay Board regulation. 7) I certify that I have complied vith my obligations related to charging and collecting fees from Medicare beneficiaries in accordance with the Medicare fee schedule, and I understand my obtigations under G.L. c. I12, sec. 28) I certi& rhat I have cornptied with my obligatiors to file Massachuseits t.u( returns ad ro pay Massachuseus taxes, and I undersrand that, pursuant to G.L. c.62C, sec. 49A, my license shalt not be issued or rerewcd udess I makc lht*e certifications under penalties of

perjury.

9) I certify tbat I have complied with my obligatioos relaled to the reporting of emptoyees and conrractors pursuant ro GI- 62E-

l0) I certifu that I

have complied wirh my obligations related to th withhotding and remiuing of child supporr pursuafi to G.L- c.t l9A.

I l) I certi$ that I have conrplied with my obligalions to file an Ircident Report with tbe Board when certain adverse everts occur in my privarc office, prrrsrant to G.L c. I 12 sec. 5 and the Patient Care Asxsment Regutations, 243 C.M.R 3.00 et seq.l understard that the Patient Carc Assessorent (PCA) programs at the heal& care facililies where I practic reporl cerrain Major Incidens ro rhc Board-

12) I certiS that I have complied with my obligations to disclose my ownership inrerest in any partnership, corporation, Iegal entity to uihich I have referred a palient for phpical therapy scn'ices pursuail to G.L. c.llZ,sec. l2AA.

firn or other

Under penalties of p*juryr I declare that I have uamined this renewal application and all it instractionsrforms and statements, and to the best of my *nowledge and belief, the information contained herein b tnte, correct, and complete. As an applicantfor renewal of a license to pradice mediciner l understand that a crtminsl record checfr msy be conductedfor coniction and pending ciminal case information from the Crtminal History Systems Board only and that it will not necessarily disqualify me fiom licensure.

signature:

MAKE A COPY OF YOUR

fu

5fu0$r,00-

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A

ATIf)N ANI} AIJ- ATTACIfiwRNTS R['-T'f}RF ilfA|I.fN(: r/NII MIIST PNTATN

Commonwealth of Massachusefts Board of Registration in Medicine Physician Renewal Application

Physician Name: Timothy P Spurrell, M.D Current Status: Active License No.: 236470 License Expiration Dale: 2fi6,2Afi

1) Activity Status: Active 2) Address & Contact lnformation

Mailing Address:

Home Address:

Business

Address:

Caring forWomen 215 Toll Gate Road, #306

Warwick Rhode lsland = 02886 United States of America

(401) 73e-2000

3) EmailAddress: 4)
Fax Number: (4O1)732-7842
Obstetrics and Gynecology

5) Specialties

6) CurrentAmerican
lnformation

Board of Medical Specialties {ABMS} or American Osteopathic Association (AOA)

ABM9AOA

ABMS

Board

Obstetrics &

Name certification Gynecotogy Obstetrics and Gynecology

Federat

subspecialty

4
8)
9)

Drug License Numbers

lltassachusetts

(DEAI

Federal(DEA)

xs

Other states where you are now licensed to practice Connecticut Rhode lsland States_where you rarere previously licensed None Reported

10) Work Sites

List of all work sites in.Massach.usetts, including health care facilities (where you are credentialed), private office, clinics, nursing homes, etc

WorkSite

Location

Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application

Physician Name: Timothy P Spurrell, M.D. License No.: 236470

21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency br conduct on yo-lrr coverage,_or have you voluntarily restricted, limited or terminated ybur insirrance coveragdin response to an inquiry by a medical liability insurance carrieP

2)

Have you completed all CME requiremenG (100 hours of CME of which 10 hours must be in risk management. Requirement: 4O hours credit in Gategory 1 and 60 hours in Category 2) for this renewal period? (lf you_are in an apfroved Resideniy/ Fellowship program, or if yourare renewing your license for the first tirne, please answer Yes)
rnray

23) Do you have a medicat condition that interferes in any medicine?

or limits your ability to practice

24) Have.you used_any chemical substance(s) which in any way interferes with your ability to

practice medicine?

D--^ a

Gommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application

Physician Name: Timothy P Spurrell, M.D. License No.: 236470

f 1) Gare

of patients in Massachusetts Average weekly hours involved in:

u

a) inpatient care 0 hrs/wk b) outpatient care 19 hrs/wk

2) h/led ical Liability I ns

rance I nformation

lnsurance Carrier

Promutual lnsurance Marsh USA, lnc

Pollqy Start Date Policy End o4n22010 04t22t2011 Date 01n1t2011 A1n1nO12

Policy Type Occurrence Policv Occurrence Policy

13) Do you perform any surgery in your Massachusetts office?

14) Claims lVlade

a) ry_ew_lqye_you received notification of a.claim, wheiher.or not a lawsuit was filed on that claim, or has 1ny medical malpractice claim been made againsl you during this time period? b) Pending: Are there any unresolved malpracti-ce cJaims againlt you toda'y, i.e., any claims that have not been resolved, seltled or adjudicated during this time pe-ioOZ
15) Claims Closed

'

Has arry-m-eOrcaj malppcflce, claim against you (whethe_r or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during this iime-period?

16) Other -

Civil Lavrauits Question 16 refers to claims or actions related to your competency to practice medicine ot your professional conduct in the practice of medicine. ' a) New: Have there been any claims, other than medical malpractice claims, filed against you during this
trme period? n)

Have you resolved, settled or adjudicated any lawsults, other than medicat matpractice 199_9ive$: clatms, during this period?

17) Griminal Charges a) Have you ben charged with any criminal offense during this period?

!J ft-lvg any criminalofenses/chaiges.against you been rEsokejO during this time period? c) Are there any criminal charges pending against you today? d) Are any Appiication of lssudnce of proiejs penOing agaihst you?

18) Other lssues a) Havg you withdrawn an application to^any governmental authority, health care facility, group practice employer or professional association? U) llly: y9u gver taken a leave of absence from any health care facility, group practice or employer? c) ll_1I?you_been the subject of.an irvestigalr.onlV any governmental'aufrhority, health care facility, group practtce, e mpl oyer or professional association? d) the.subject of a disciplinary.action taken by any governmentat authority, heatth care l]?Y9- youbeen Iactttty, group practice, employer or professional association?

19)

privileges.to possess, dispense or. prescribe controlled substances been suspended, revoked, denied, restricted by or surrendered to any state or federal agency?
fl_?y-E_Y9ur

20) Have you withdrawn_an application for a medical license, allowd a license application to become obsolete or have you been denied a medical license for any reason?' '

Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application

Physician Name: Timothy P Spurrell, M.D. License No.: 236470

Online profile:

Compliance with Legal Responsibilities

I I hdve reviewed my Physician Profile and confirm that the information is accurate. 1) I understand and agree to comply with my obligations to rgport abuse or neglect of children pursuant to ' M.G.L. c. 119 sec. 51A and I und'erstandihe pinishment fcir failure to compTy.
I understand and agree to comply with my obligations to report abuse or neglect of disabled persons pursuant to M.G.L. c. 19C sec. 10 and I understand the punishment for failuie to compty. I understand and agree to comply with my obligations to report abuse, neglect or Financial exploitation of elderly persons pursuant to M.G L c '19A sec. 15 and I understand the punishment for fallure to comply.

2) 3)
4)

I understand and agree to comply with rrry obligations to report the treatment of wounds, burns and other inJuries pursuant to M.G.L. c. 112 sec. 12A and I understand the punishment for failure to comply.
I unde.rstand and agree, to comply with my obligations to report the treatment of victims of rape or sexual assault pursuant to M.G.L. c. 112 sec. 124 1f2 at:d I understand the punishment for failure tb comply.

5) 6) 7) 8) ' 9)

I understand and agre-e-to comply with nry obligations to report a physical to the Board of Medicine pursuant to M.G.L. c. 112 sec. 5F, when i have a reasonable hsis to believe that a person violated arry provisions of

M.G.L. c.112 sec. 5 or arnT Board regulation.

I understand and agree to comply with rny obligations related to charging and collecting fees from Medicare benefrqarles in accordance with the Medicare fee schedule; pursuant to M.G.L. c. 112 sec: 2.

understand and have complied with rny obligations to file Massachusetts tax returns and to pay Massachusetts taxes and I understand that, dursuant to M.G.L. c. 62C sec. 49A. rnir license inatt not Oe issued or renewed unless I make this certification under penalties of perjury.
I

I understand and agree to comply with rny obligations related to the reporting of the wages of employees and contractors pursuant to M.G.L. c. 62E Sec. 2.

1O)l understand and agree to comply with my obligations related to the withholding and remitting of child support payments pursuant to M.G.L. c. 119A.
11) I understand and agree to comply with my obligations to

file an lncident Report with the Board when certain adverse events occr.{ in nry private office, pursqant to M.G.L c. 112 sec. 5 and 243 CMR 3.00 et seq. and I understand that the Patient Care Assessment (PCA) programs at the health care facilities where I piactice report certain Major lncidents to the Board.

12)l understand-and agree to comply.with rny obligations to disclose ownership interest in any partnership, corporation,.flrry gr other legal entity to which l-have referred a patient for pihysical therapy iervices, ' pursuant to M.G.L c. 112 sec. 12AA.

{3}l am aware of my obligations and responsibilities under the Health lnsurance Portabilitv and Accourrtabilitv Act oJ 1996 (HIPAA), including the requirement that I obtain and provide to the Board d National Provider'
ldentifier (NPl) number. 14)l understand and am in compliance with HIPAA and all otherfederal and state obligations placed upon me as a pnystctan. 15)l understan-d that as an applicant for a license renewal to practice medicine a criminal record check may be conducted for convictlon and pending criminal case information only from the Criminal History Systems' hard and that it will not necessarily disqualiflT me.

E EI

l.have review-ed the above statements and certify that I understand my requirement to comply with the responsibilities and obligations of each and agree to do so.
acco-mP.anytllg in_structions, forms and statements, and to the best of my'knowledge and belief,

Under penafties of perjury, I declare that I have examind this ranewat application and all of its

certify that the information contained herein is true, accurate, and complete.