STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF PROFESSIONAL ) REGULATION, BOARD OF MEDICINE, )

)

Petitioner, )

)

vs. ) CASE NO. 91-3696

)

SHAMSHER SINGH, M.D., )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was conducted in this case on October 30, 1991, in Port St. Lucie, Florida, before Stuart M. Lerner, a duly designated Hearing Officer of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Mary B. Radkins, Esquire

Department of Professional Regulation 1940 North Monroe Street, Suite 60

Tallahassee, Florida 32399-0792

For Respondent: Shamsher Singh, M.D., Pro Se

1701 Hillmoor Drive, #A-3 Port St. Lucie, Florida 34952

STATEMENT OF THE ISSUES

1. Whether Respondent committed the offenses described in the Administrative Complaint?

   
   

2. If so, what disciplinary action should be taken against him?

   
   

   PRELIMINARY STATEMENT

   
   

   On May 15, 1991, the Department of Professional Regulation (Department) issued an Administrative Complaint alleging that Respondent violated Section 458.331(1)(t), Florida Statutes, by "fail[ing] to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances, in that Respondent failed to perform a routine biopsy on Patient #1's [E.M.'s] left forearm, and thereby failed to adequately diagnose and treat Patient #1's condition in a timely manner." The Administrative Complaint contained the following factual allegations describing the care and treatment Respondent provided the patient in question:

   
   

3. From on or about June 29, 1988, to on or about July 27, 1988, Respondent provided medical care and

   treatment to Patient #1.

4. On or about July 13, 1988, Patient #1 presented to Respondent for treatment of a pigmented lesion on Patient #1's forearm, and Respondent diagnosed solar keratosis.

5. On or about July 13, 1988, Respondent performed cryosurgery on Patient #1's lesion.

6. On or about July 27, 1988, Patient #1 returned to Respondent, who noted that the lesion on Patient #1's left forearm was slowly healing. Respondent's office note on this date indicates that Respondent advised Patient #1 to have the pigmented lesion biopsied; however, Respondent failed to perform or order a routine biopsy of Patient #1's lesion.

Respondent denied the allegation of wrongdoing made in the Administrative Complaint and requested a formal hearing. On June 14, 1991, the matter was referred to the Division of Administrative Hearings for the assignment of a Hearing Officer to conduct the formal hearing Respondent had requested.

At the formal hearing held in this matter, the live testimony of seven witnesses was presented: E.M., the patient referenced in the Administrative Complaint; F.M., his wife; Respondent; David Dimon, a medical quality assurance investigator with the Department; and Donato Viggiano, M.D., a plastic surgeon, Gary Marder, D.O., a dermatologist, and Roshan Singh, M.D., an oncologic surgeon, all of whom treated E.M. after he had been seen by Respondent. In addition to the live testimony of these witnesses, ten exhibits were offered and received into evidence. Among these exhibits were the depositions of Louis Kloep, M.D. and Larry Garland, M.D., both of whom are dermatologists. Kloep's and Garland's depositions were offered and received in lieu of their live testimony.

At the conclusion of the evidentiary portion of the hearing, the Hearing Officer advised the parties on the record that post-hearing submittals had to be filed no later than ten days following the Hearing Officer's receipt of the transcript of the hearing. The Hearing Officer received the hearing transcript on November 18, 1991. On November 21, 1991, the Department filed a motion requesting an extension of the deadline for the filing of post-hearing submittals. By order issued November 22, 1991, the motion was granted and the deadline for the filing of post-hearing submittals was extended to December 5, 1991. On December 3 and 5, 1991, respectively, Respondent and the Department filed their post-hearing submittals. These post-hearing submittals have been carefully considered by the Hearing Officer. Respondent's post-hearing submittal consists of written argument. It does not contain any proposed findings of facts that are labeled as such. The Department's post-hearing submittal, on the other hand, which is in the form of a proposed recommended order, does contain such proposed findings of fact. These findings of fact proposed by the Department are specifically addressed in the Appendix to this Recommended Order.

FINDINGS OF FACT

Based upon the record evidence, the following Findings of Fact are made:

1. Respondent is now, and has been since October 18, 1977, a physician authorized to practice medicine in the State of Florida under license number ME 0013979. He is a board certified dermatologist and dermapathologist.

   Respondent's practice is located in St. Lucie County. He is the only dermapatholgist in the county.

   
   

2. E.M. is a former patient of Respondent. He is a fair complected retiree with red hair who has lived his entire life in areas that have warm and sunny climates.

   
   

3. Fair complected individuals are more prone to develop skin cancers as a result of exposure to the sun than are their darker complected counterparts.

   
   

4. E.M. had been treated for skin cancer on several occasions, dating back to some time between 1954 and 1960, before becoming Respondent's patient.

   
   

5. In June of 1988, E.M. became concerned about two lesions that he had in a dime-sized area on his left forearm below the elbow. The lesions were scaly and crusted in texture, pea-sized in diameter, irregularly shaped, reddish in color and sensitive to the touch.

   
   

6. E.M.'s concern led him to make an appointment to see Respondent.

   
   

7. His initial visit to Respondent's office was on June 29, 1988.

   
   

8. Because he was a new patient, E.M. filled out a medical history form before going into the examining room.

   
   

9. Respondent did not give E.M. a complete physical examination. He examined only E.M.'s left forearm.

   
   

10. His examination revealed the lesions about which E.M. was concerned. These were not the only lesions Respondent discovered on E.M.'s left forearm, however.

    
    

11. By all appearances, the lesions on E.M.'s left forearm were pre- cancerous growths. There was no evidence of any ulceration, discharge, bleeding or other indication that these lesions were malignant.

    
    

12. Having no reason to suspect that these lesions were cancerous, Respondent determined that they were solar keratoses, which are pre-malignant growths that appear on the superficial layers of sun damaged skin.

    
    

13. E.M. had told Respondent before the examination that he had previously used Efudex, which is a chemotherapeutic drug used in the treatment of solar keratoses. Accordingly, at the time he made his diagnosis, Respondent knew that

    E.M. had a history of pre-cancerous growths.

    
    

14. As a general rule, Respondent treats growths of the type he found on E.M.'s left forearm with cryosurgery1 and cauterization.2 If, after two or three such treatments, sufficient progress has not been made, he will then perform a biopsy to determine if there are cancerous cells in the deeper layers of the skin.

    
    

15. In accordance with his usual practice, Respondent, during E.M.'s first visit on June 29, 1988, treated the lesions on E.M.'s left forearm, which Respondent reasonably believed to be pre-cancerous growths, with cryosurgery and cauterization.

16. He then gave E.M. a cortisone cream to apply to the treated areas to aid the healing process.

    
    

17. An appointment for a follow-up visit was made for July 13, 1988.

    
    

18. Respondent next saw E.M. on July 13, 1988.

    
    

19. His examination of E.M.'s left forearm on July 13, 1988, did not reveal any evidence of a malignancy, however, he did determine that there was a need to, and therefore he did, perform additional cryosurgery.

    
    

20. Respondent sent E.M. home with a cream that contained not only cortisone to aid in healing, but an antibiotic as well to prevent against infection.

    
    

21. An appointment for a second follow-up visit was made for July 27, 1988.

    
    

22. E.M.'s next visit to Respondent was on July 27, 1988.

    
    

23. Respondent's examination of E.M.'s left forearm on July 27, 1988, revealed that the treated areas were slowly healing. Based upon his examination, he had no reason to suspect a malignancy. Nor was there any indication that further cryosurgery was necessary.

    
    

24. Respondent noted a flat, pigmented lesion in close proximity to the areas on E.M.'s left forearm that had been treated during his two previous visits. Respondent was not particularly concerned about this lesion,3 but he nonetheless mentioned to E.M. that it might be a good idea to have it biopsied to be on the safe side. E.M. responded that he preferred that such a biopsy not be performed. Respondent did not pursue the matter any further during the visit.

    
    

25. Once again, Respondent gave E.M. a different cream to apply to the areas that had been treated. This time it was a pure antibiotic ointment.

    
    

26. An appointment for a third follow-up visit was made for the morning of Wednesday, August 10, 1988. Respondent typically schedules biopsies and excisions on Wednesday mornings.

    
    

27. E.M. cancelled his August 10, 1988, appointment with Respondent. He did not make another appointment. Accordingly, Respondent did not see E.M. as a patient again.

    
    

28. In failing to biopsy the lesions on E.M.'s left forearm, which he had no reason to suspect were cancerous, Respondent did not act in a manner that was inconsistent with what a reasonably prudent physician with his training and experience would have done under like circumstances.

    
    

29. More than a year later, in September, 1989, E.M. noticed that a lesion on his left forearm had opened and was draining.

    
    

30. E.M. went to see Dr. Gary Marder, an osteopathic physician who specializes in dermatology.

    
    

31. Marder suspected a malignancy. Accordingly, he performed a biopsy and scheduled E.M. for surgery.

32. The initial biopsy report indicated an "invasive moderately differentiated squamous cell carcinoma."

    
    

33. After Marder surgically excised the area, the pathologist revisited the matter and changed his diagnosis to an amelanotic melanoma, which is a rare type of melanoma4 that is characterized by an absence of pigmented cells.

    
    

34. Pigmented lesions, like the one Respondent noticed on E.M.'s left forearm during E.M.'s July 27, 1988, visit, are not precursors of amelonotic melanomas.

    
    

35. It was subsequently determined that the cancer had spread. Cancerous lymph nodes were removed from E.M.'s axilla in April, 1990, and from his elbow in November, 1990.

    
    

    CONCLUSIONS OF LAW

    
    

36. The Board of Medicine (Board) is statutorily empowered to take disciplinary action against a physician licensed to practice medicine in the State of Florida based upon any of the grounds enumerated in Section 458.331(1), Florida Statutes.

    
    

37. Where the disciplinary action sought is the revocation or suspension of the physician's license, the proof establishing the physician's guilt must be clear and convincing. See Section 458.331(3), Fla. Stat.; Ferris v. Turlington, 510 So.2d 292 (Fla. 1987); Pascale v. Department of Insurance, 525 So.2d 922 (Fla. 3d DCA 1988). "The evidence must be of such weight that it produces in the mind of the trier of fact a firm belief or conviction, without hesitancy, as to the truth of the allegations sought to be established." Slomowitz v. Walker, 429 So.2d 797, 800 (Fla. 4th DCA 1983).

    
    

38. Where the discipline does not involve the loss of licensure, the physician's guilt need be established by only a preponderance of the evidence. See Section 458.331(3), Fla. Stat.; Allen v. School Board of Dade County, 571 So.2d 568, 569 (Fla. 3d DCA 1990).

    
    

39. Regardless of the disciplinary action taken, it may be based only upon the offenses specifically alleged in the administrative complaint. See Kinney

    v. Department of State, 501 So.2d 129, 133 (Fla. 5th DCA 1987); Hunter v. Department of Professional Regulation, 458 So.2d 842, 844 (Fla. 2d DCA 1984).

    
    

40. The Administrative Complaint issued in the instant case alleges that disciplinary action should be taken against Respondent because he "failed to perform a routine biopsy on [E.M.'s] left forearm, and thereby failed to adequately diagnose and treat [E.M.'s] condition in a timely manner" in violation of 458.331(1)(t), Florida Statutes.

    
    

41. Section 458.331(1)(t), Florida Statutes, provides in pertinent part as follows:

    (1) The following acts shall constitute grounds for which the disciplinary actions specified in subsection (2) may be taken:

    
    

    (t) Gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar

    conditions and circumstances. The board shall give great weight to the provisions of s. 766.102 when enforcing this paragraph. . . . As used in this paragraph, "gross malpractice" or "the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances," shall not be construed so as to require more than one instance, event or act. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph.

    
    

42. Section 766.102, Florida Statutes, to which the Board must "give great weight" in determining whether there has been a violation of Section 458.331(1)(t), Florida Statutes, provides as follows:

    
    

    1. In any action for recovery or damages based on the death or personal injury of any person in which it is alleged that such death or injury resulted from the negligence of a health care provider . . . , the claimant shall have the burden of proving by the greater weight of the evidence that the alleged actions of the health care provider represented a breach of the prevailing professional standard of care for that health care provider. The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers.

       * * *

       (2)(b) If the health care provider whose negligence is claimed to have created the cause of action is certified by the appropriate American board as a specialist, is trained and experienced in a medical speciality, or holds himself out as a specialist, a "similar health care provider" is one who:

       1. Is trained and experienced in the same specialty; and

       2. Is certified by the appropriate American board in the same specialty.

       * * *

       1. The existence of a medical injury shall not create any inference or presumption of negligence against a health care provider, and the claimant must maintain the burden of proving that an injury was proximately caused by a breach of the prevailing professional standard of care by the health care provider.

       2. The Legislature is cognizant of the changing trends and techniques for the delivery of health care in this state and the discretion that is inherent in the diagnosis, care, and treatment of patients by different health care providers. The failure of a health care provider to order, perform, or administer supplemental diagnostic tests shall not be actionable

       if the health care provider acted in good faith and

       with due regard for the prevailing professional standard of care.

       
       

43. The Department has not demonstrated by even a preponderance of the evidence that, in failing to biopsy the lesions on E.M.'s left forearm during the time that E.M. was under his care, Respondent acted without "due regard for the [applicable] professional standard of care." Given the benign appearance of these lesions, Respondent's "wait and see" approach was entirely appropriate and acceptable, notwithstanding that E.M. may have had a history of skin malignancies.

    
    

44. There is no obligation on the part of a physician who is treating a patient like E.M. with multiple skin lesions and a history of skin malignancies to biopsy each and every lesion, regardless of their appearance. Only those lesions which the physician has reason to suspect may be cancerous should be biopsied. While E.M. may have had such suspicious lesions on his left forearm when he went to see Dr. Marder in September 1989, this was more than a year after he had unilaterally severed his relationship with Respondent. At no time while he was still under Respondent's care did the lesions on E.M.'s left forearm appear to be cancerous.

44. Accordingly, Respondent did not act in derogation of the prevailing professional standard of care by failing to biopsy these lesions. The Administrative Complaint, which asserts the contrary, should therefore be dismissed in its entirety.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby

RECOMMENDED that the Board of Medicine enter a final order dismissing the instant Administrative Complaint against Respondent in its entirety.

DONE AND ENTERED in Tallahassee, Leon County, Florida, this 23rd day of January, 1992.

STUART M. LERNER

Hearing Officer

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 23rd day of January, 1992.

1/ Respondent uses liquid nitrogen to freeze and destroy the unwanted tissue.

2/ The cautery device that Respondent uses is battery-operated and produces a low current. It is particularly effective in removing rough, hard-crusted areas of skin.

3/ It did not even appear to be a pre-cancerous condition.

4/ Melanomas are one of the three types of skin cancers. Basal cell carcinomas and squamous cell carcinomas, which together account for 98% of all cancers, are the two other types. Of these three types of cancers, melanomas are the most destructive and the most likely to metastasize.

5/ Respondent has not been charged with failing to keep adequate medical records.

6/ Precisely what information E.M. provided on this form is unclear.

7/ The issue is not whether the practice described in this proposed finding is common, but whether it is acceptable.

8/ As noted above, the adequacy of Respondent's medical records are not at issue in the instant case.

9/ The Department did not advance this theory in the Administrative Complaint.

APPENDIX TO RECOMMENDED ORDER IN CASE NO. 91-3696

The following are the Hearing Officer's specific rulings on the findings of fact proposed by the Department:

1. Accepted and incorporated in substance, although not necessarily repeated verbatim, in this Recommended Order

2. First sentence: Accepted and incorporated in substance; Second and fourth sentences: Rejected because they are more in the nature of summaries of testimony than findings of fact; Third sentence: To the extent that this proposed finding suggests that there was also a "pigmented lesion" on E.M.'s left forearm that Respondent observed during E.M.'s first visit to his office, it has been rejected because it is not supported by persuasive competent substantial evidence.

3. Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.5

4. First sentence: Accepted and incorporated in substance;6 Second sentence: Rejected because, even if true, it would have no bearing on the outcome of the instant case.

5. Rejected because, even if true, it would have no bearing on the outcome of the instant case.

6. First sentence: Accepted and incorporated in substance; Second sentence: Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

7. Rejected because, even if true, it would have no bearing on the outcome of the instant case.

8. Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

9. Rejected because, even if true, it would have no bearing on the outcome of the instant case.

10. First sentence: Accepted and incorporated in substance; Second sentence, fragment before comma: Accepted and incorporated in substance;

Second sentence, fragment after comma: Rejected because, even if true, it would have no bearing on the outcome of the instant case.

11-12. Accepted and incorporated in substance.

13. Rejected because, even if true, it would have no bearing on the outcome of the instant case.

14-17. Accepted and incorporated in substance.

1. Rejected because, even if true, it would have no bearing on the outcome of the instant case.7

2. First sentence: Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer; Second sentence: Accepted and incorporated in substance.

3. First sentence: Accepted and incorporated in substance; Second sentence: Rejected because it is more in the nature of a summary of testimony than a finding of fact; Third sentence: To the extent that this proposed finding suggests that Respondent believed that the pigmented lesion was a squamous cell carcinoma, it is rejected because it is not supported by persuasive competent substantial evidence.

4. First sentence: Rejected because it is more in the nature of a summary of testimony than a finding of fact; Second sentence: Accepted and incorporated in substance; Third sentence: Rejected because it constitutes argument regarding the credibility of testimony rather than a finding of fact.

5. Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.8

6. First sentence: Rejected because it is more in the nature of a summary of testimony than a finding of fact; Second sentence: To the extent that this proposed finding states that "E.M. had had several prior biopsies . .

   . [and therefore] was aware of the reasons for a biopsy," it has been accepted and incorporated in substance. To the extent that it suggests that Respondent never recommended to E.M. that a biopsy be performed on the pigmented lesion that Respondent observed on E.M.'s left forearm during the July 27, 1988, visit and that, if such a recommendation had been made, E.M. "would have willingly submitted," it has been rejected because it is contrary to the greater weight of the evidence.

7. Rejected because, even if true, it would have no bearing on the outcome of the instant case.

8. Accepted and incorporated in substance.

9. First sentence: Rejected because it is not supported by persuasive competent substantial evidence; Second and third sentences: Rejected because they would add only unnecessary detail to the factual findings made by the Hearing Officer.

10. First sentence: Rejected because it is more in the nature of a recitation of testimony than a finding of fact; Second sentence: Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

28-29. Rejected because they would add only unnecessary detail to the factual findings made by the Hearing Officer.

30-34. Accepted and incorporated in substance.

1. Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

2. Third sentence: Accepted and incorporated in subst ance; Remaining sentences: Rejected because they would add only unnecessary detail to the factual findings made by the Hearing Officer.

3. Rejected because it would add only unnecessary detail to the factual findings made by the Hearing Officer.

4. Rejected because, even if true, it would have no bearing on the outcome of the instant case.

5. Rejected because it is contrary to the greater weight of the evidence.

6. Rejected because, even if true, it would have no bearing on the outcome of the instant case.9

COPIES FURNISHED:

Mary B. Radkins, Esquire

Department of Professional Regulation 1940 North Monroe Street, Suite 60

Tallahassee, Florida 32399-0792

Shamsher Singh, M.D.

1701 Hillmoor Drive, #A-3 Port St. Lucie, Florida 34952

Dorothy Faircloth, Executive Director Board of Medicine

Department of Professional Regulation 1940 North Monroe Street

Tallahassee, Florida 32399-0792

Jack McRay, General Counsel Department of Professional

Regulation

1940 North Monroe Street Tallahassee, Florida 32399-0792

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

ALL PARTIES HAVE THE RIGHT TO SUBMIT WRITTEN EXCEPTIONS TO THIS RECOMMENDED ORDER. ALL AGENCIES ALLOW EACH PARTY AT LEAST 10 DAYS IN WHICH TO SUBMIT WRITTEN EXCEPTIONS. SOME AGENCIES ALLOW A LARGER PERIOD OF TIME WITHIN WHICH TO SUBMIT WRITTEN EXCEPTIONS. YOU SHOULD CONTACT THE AGENCY THAT WILL ISSUE THE FINAL ORDER IN THIS CASE CONCERNING AGENCY RULES ON THE DEADLINE FOR FILING EXCEPTIONS TO THIS RECOMMENDED ORDER. ANY EXCEPTIONS TO THIS RECOMMENDED ORDER SHOULD BE FILED WITH THE AGENCY THAT WILL ISSUE THE FINAL ORDER IN THIS CASE.

=================================================================

AGENCY FINAL ORDER

=================================================================

DEPARTMENT OF PROFESSIONAL REGULATION BOARD OF MEDICINE

DEPARTMENT OF PROFESSIONAL REGULATION,

Petitioner,

vs. DPR CASE NUMBER: 90-00042

DOAH CASE NUMBER: 91-3696

SHAMSHER SINGH, M.D., LICENSE NUMBER: ME 0031654

Respondent.

/

FINAL ORDER

This cause came before the Board of Medicine (Board) pursuant to Section 120.57(1)(b)10, Florida Statutes, on Apri1 3, 1992, in Jacksonville, Florida, for the purpose of considering the Hearing Officer's Recommended Order (a copy of which is attached hereto as Exhibits A) in the above-styled cause.

Petitioner, Department of Professional Regulation, was represented by Mary Radkins, Attorney at Law. Respondent was present at the hearing.

Upon review of the Recommended Order, the argument of the parties, and after a review of the complete record in this case, the Board makes the following findings and conclusions.

FINDINGS OF FACT

1. Findings of fact set forth in the Recommended Order are approved and adopted and incorporated herein with the exception of the ministerial error as to Respondent's license number. The correct number is ME 0031654.

   
   

2. There is competent substantial evidence to support the findings of fact as corrected.

CONCLUSIONS OF LAW

1. The Board has jurisdiction of this matter pursuant to Section 120.57(1), Florida Statutes, and Chapter 458, Florida Statutes.

   
   

2. The conclusions of law set forth in the Recommended Order are approved and adopted and incorporated herein.

   
   

3. There is competent substantial evidence to support the conclusions of

law.

DISPOSITION

Upon a complete review of the record in this case, the Board determines

that the disposition recommended by the Hearing Officer be ACCEPTED AND APPROVED. WHEREFORE,

IT IS HEREBY ORDERED AND ADJUDGED that

The Administrative Complaint is hereby DISMISSED.

This order takes effect upon filing with the Clerk of the Department of Professional Regulation.

DONE AND ORDERED this 20th day of April , 1992

BOARD OF MEDICINE

ZACHARIAH P. ZACHARIAH, M.D, CHAIRMAN

NOTICE OF RIGHT TO JUDICIAL REVIEW

A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW PURSUANT TO SECTION 120.68, FLORIDA STATUTES. REVIEW PROCEEDINGS ARE GOVERNED BY THE FLORIDA RULES OF APPELLATE PROCEDURE. SUCH PROCEEDINGS ARE COMMENCED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF THE DEPARTMENT OF PROFESSIONAL REGULATION AND A SECOND COPY, ACCOMPANIED BY FILING FEES PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL, FIRST DISTRICT, OR WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE PARTY RESIDES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing Order has been provided by certified mail to Shamsher Singh, M.D., 1701 S.E. Hillmoor Drive, #A-3, Port Saint Lucie, Florida 34952, by U.S. Mail to Stuart M. Lerner, Hearing Officer, Division of Administrative Hearings, The DeSoto Building, 1230 Apalachee Parkway, Tallahassee, Florida 32399-1550; and by - interoffice delivery to Larry G. McPherson, Jr., Chief Medical Attorney, Department of Professional Regulation, 1940 North Monroe Street, Tallahassee Florida 32399- 0792 at or before 5:00 P.M., this 20th day of April , 1992

DOROTHY J. FAIRCLOTH

Docket for Case No: 91-003696

Orders for Case No: 91-003696