STATE OF FLORIDA DEPARTMENT OF HEALTH mot oD om he. 4 Gobi 77 joie BUREAU OF EMERGENCY MEDICAL SERVICES, Petitioner, OS: -O G0 p L Case No.: 02-0658 STEVEN R. BOX, Paramedic Certificate #200933 and * on eres i. der at SS ea Emergency Medical Technician Certificate #86759 te op Respondent. es 3° / * ADMINISTRATIVE COMPLAINT me) COMES NOW Petitioner, the Florida Department of Health, Bureau of Emergency Medical Services (hereinafter “Bureau” or “Petitioner”) and files this Administrative Complaint against Respondent Steven R. Box, (hereinafter “Box” or “Respondent ”) and alleges the following: ESSENTIAL ALLEGATIONS OF MATERIAL FACT 1. ‘The Bureau of Emergency Medical Services is a state government regulatory agency charged with the responsibility and duty to pro: secute Administrative Complaints pursuant to the laws of the State of Florida, in particular §720.60(5), Florida Statutes and Chapter 401, Florida Statutes, and Florida Administrative Code Chapter 64E-2 promulgated pursuant thereto. 2. On or about December 21, 2000, the Bureau of Emergency Medical Services received an applicatio 3. n for certification as a paramedic in Florida from Steven R. Box. On the application Box swore an oath on December 5, 2000, stating, in part, “I understand that any fraudulent entry may be considered as cause for rejection or subsequent voiding of certification.” 4. With the application, Box submitted a Statement of Good Standing which states, in pertinent part, “T, the below named EMT/paramedic, am requesting Florida certification based on training and current certification in the State of Georgia or by National Registry of EMTs.” 5. Box’s Statement of Good Standing was verified by Robert Vick, EMS Coordinator, Region 8 EMS Office/Ga DHR, and indicated “yes” to the following statement, “Is the above certificate current and valid in the Georgia EMS Office or with the National Registry of EMTs.” A copy of the application and statement of good standing is attached hereto, incorporated herein and made a part hereof by reference as Exhibit 1. 6. At no time material to the allegations herein was Box certified as an EMT or paramedic by the National Registry of EMTs or the State of Georgia. COUNT I Based on the foregoing, Box is guilty of violating Section 401.411(1)(@), Florida Statutes, by making false or fraudulent claims to procure or attempt to procure a certificate as a paramedic. COUNT I Based on the foregoing, Box is guilty of violating Section 401.411(1)(f), Florida Statutes, by knowingly procuring or attempting to procure a certificate by fakery, fraudulent action, or misrepresentation. COUNT Ul Based on the foregoing, Box is guilty of violating Section 401.411(1)(a), Florida Statutes, by violating a provision of this part, fowit. Section 401.27, Florida Statutes, by seeking paramedic certification without having met the requirements. COUNT IV Based on the foregoing, Box is guilty of violating Section 401.411(1)(a), Florida Statutes, by violating a rule of the department, towit, Fla. Admin. Code R. 64E-2.009(1)(b) which requires applicants for certification as a paramedic to currently hold a valid paramedic certification from the National Registry of Emergency Medical Technicians or be currently certified in another state or US. territory. WHEREFORE, the Bureau of Emergency Medical Services requests the Department of Health to issue a Final Order as final agency action finding Box guilty as charged and impose an administrative fine not to exceed one thousand dollars ($1,000) per count, suspend Box’s paramedic certification #200933 or revoke Box’s paramedic certification #200933, as provided in §401.471(7), Florida Statutes. SIGNED this 7] PH say of May, 2003. BY: Phil E. Williams Director Division of Emergency Medical Services and Community Health Resources ine B, Myrick, Esquire S@nior Attorney for Bureau Fh. Bar No. 621749 4052 Bald Cypress Way, BI Tallahassee, FL 32399-1703 TEL: 850/245-4005; FAX: 850/413-8743 #A02 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Administrative Complaint has been furnished by Certified U.S. Mail (Receipt Noy 7000 0600 0027 1547 4131) to Steven R. Box, 308 Heron Lane, Monticello, Florida 32344 this “ce day of May, 2003. WARNING TO RESPONDENT If you do not file an Election of Rights form or some other responsive pleading with the Bureau within twenty-one (21) days of receipt of this Administrative Complaint, the Bureau will file with the Department of Health, a motion seeking a Final Order finding you in default and imposing penalties. Please see the enclosed Elections of Rights form. K:\AlbrittonCY \JMyrick\EMS PC 13103\Box Comp.doc BUREAU OF EMERGENCY MEDICAL SERVICES . FLORIDA DEPARTMENT OF HEALTH Statement of Good Standing 3025 caprrat CIRCLE SOUTHEAST, BIN Cta from TALLAHASSEE, FL 32399-1738 State Certifying Agency or National Registry Applicants with out-of-state certification are to complete Part I and mail this form to the issuing state certification board or National Registry. Part II is to be completed by the state certifying agency or National Registry, P.O. Box 29233, Columbus, BH 4322)-21 ‘he agency will then mail or fax this form to Florida EMS per instructions in Pact III. wa Part I. To be completed by applicant: nos I, the below named d EMT'/paramedic, am requesting Florida certification based on training and curent m ceglificaticn§ in, the State of é A or by National Registry of EMTs. Name: ‘ Applicant's Current Address: RT g Box SSS, oy MONTICE LLo 323 4Y Certificate Type: {(] EMT-Basic a Certificate No. LJ Other: Expiration Date Part II. To Be Completed by National Registry or State Certifying Agency. Please assist by verifying this individual is currently certified and in good standing according to your certification policies. A. Is the above certificate current and valid in the G emp a EMS Office or with the National Registry of EMTs? (state) [7] Yes [7] No If no, why not? Has the above certificate ever been revoked or suspended? [4] Yes [KJ No Tf yes, please explain Has the above individual ever been convicted of a felony? [J Yes No [7] Unknown If yes, when?. where? D. Do you know of any reason certification in Florida should be denied? CL] Yes KZ No If yes, why? 5 Verifying Person's Name: ca LL Tite 42s Cora tool Dv Q Agency Name: ‘Cou 2 Gms OO ef fea De Phone Number:_ 22-7> 2°96: 2o 357 Date: [i-~c¥-¢o Part Il To be mailed to: ‘he return of this form is necessary before processing can be completed. Mail or Fax to Schragden MMe nane «€chnologies, Inc., 2494 Bayshore Blvd., Suite 201, Dunedin, FL 34698, or F EXHIBIT Direct questions to EMS, 2020 Capital Circle Southeast, Bin C18, Tallahassee, FL 32399 4 a PHWORKREGSERIRECIPROC.P85 Mar. 09 oY ONLY ' "URN THIS PAGE 1.0 Exam Purpose & Level meee nee MAIL TO: @ Boyleyard, Suite 201 34698 4 Must type or print (Black Ink) in CATAL LETTERS as this form wit be scanned by 2494 Sin FL computer, Place X in Proper Dunedin, 5 Box ( [gj Example) s(pooyssstoasa ) = > Schroeder Measurement Technologies, Inc. 1.1 Florida Exam & Certification 1.2 Florida Exam Only 1.3 In State Trained with Fee $40 NREMT Certification OEMT-B Tots! Fee $75 0 EMT-B 0 EMT-B - Fee $35 “US DOT 1964 Curriculum US DOT 1994 Curriculum fAParamedic - Total Fee $85 (0 Paramedic Paramedic - Fee $45 Send to EMS - Tallahassee 2. Equat Opportunity Data: This information is gathered for statistical and reporting purposes onty and does not in any way affect your candidacy for ceftification. Sex, Race: W Mae (0 Black C} White Hispanic DX Caucasian Female 1 Native American (Indian) [1 Slack Hispanic 0) Asian/Pacific Is. 2308 FES -2 a 1: 20 Recaived On Time Form Notarized Two Original Pictures Certificate Attached CPR/ACLS Card Attached Good Standing Statement Fees Attached Accepted Verified Certificate # Issued ts orzutn| 7 2. ie ($50) 997-9797 a (3171 M.I. Area Code Home Phone (MOI FICELCE City (Attach h copy of certificate and CPR or ACLS card.) ; a Enter Training Program Code ue A567? ! LAW, A. Name of Florida Training Program From Back of Form Completion Dale ” Mons [soe [{ ] 8. Reexamination Info (when B. Outot-State Certiied: 399-003] seebextoncose| MO7 DAY? YEAR applicable) . e . If previously falled the Florida exam, fist date of last exam failed: (Name of State} (Cortficate Number) 1SQ9.005 | tBpintiondatey: Cc. Nationally Registered: / Month Year = {National Registry Number) (Expiration Date} D. Health Professionals (F.N..M.D., Dentist) | SO9-053 _ 6, Oo Yes [%4 No (Profession) {FL License Number) (Expiration Dale) What Charges: E. HIWAIDS Training 4 hours minimum inservice required. Where Convicted: —_— ——-— Professional Rescuer Card No. Hours Date Completed Date Convicted: (If yes, must attach a description.) See instructions For EMT a two man CPR Card, for paramedic an ACLS card. (Qssuing Organization) (CourseLevel) 9. Qath: | certify (A) 1am free from addiction to alcohol or any controlled substance and that (B) ! am free from any physical or mental defect or disease that might impair my ability to perform as an emergency medica! technician or paramedic. | understand that any fraudulent entry may be considered as cause for rejection or subsequent voiding of certification. | Jyndesstand that applications are public records and must be received 30 days prior to the @am date. A Applicant Signature: Date: Wateo Swom to and subscribed before methis 57° day of _, Derember 280 Personality known or type ID produced Notary Signature: Expires: Alec 13 204 Printed Name: _.Smana A. Thomas FL Commission # CC A uae. ered bali nmueeretowan (Renewal Date} ONLY RETURN THIS PAGE | ie ee BASIC TRAUMA LIFE SUPBORT = STATE OF FLORIDA wwe (BAUM LIEE SUPROE . te Adverced Course 34819 3 EMERGENCY MEDICAL SERVICES . on CERTIEIES BOX, STEVEN R. ASA — Emergency Medical Technician UNDER PROVISIONS OF CHAPTER £04 TS. , For the period ending midnight 42/1/02 ate Number 86759 D:¥ Dale issued 10/18/0 oe Sains a AUDIT comvace 0 JEB BUSH STEVE Box Too7syy GOVERNOR — - rEeefey Compl ww TE seat you zo RE Loos ~. MELISSA PULLEN Ss a FILE LICENSE NUMBER B200-796-57-468-0 STEVEN ROBERT BOX Teqneyss weryt yy ? RT 6 BOX 5551 MONTICELLO, FL 32344-8221 ~y: BIRTH OATE SEX HGT. REST. ENDORS Te2095 Tespuyssy ATBATI 12-28-67 1K 5414 E : ISSUED EXPIRES DUPLICAT 5 4047-09 12-28-05 0.00.0 491U38) Testuysay ATSATT ePpraorTg voibey yin 10 awey SAFE DRN BrI0019179013 Operation of a moto: vehicte constitutes consent to a ety test required by bx

Docket for Case No: 05-000390PL