se STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, PETITIONER, vs. CASE NUMBER: 99-59159 MICHAEL HERSHORN, RESPONDENT. ADMINISTRATIVE COMPLAINT COMES NOW, the Petitioner, Department of Health, hereinafter referred to as "Petitioner", and files this Administrative Complaint before the Board of Psychology against MICHAEL HERSHORN, hereinafter referred to as "Respondent", and alleges: 1. Effective July 1, 1997, Petitioner is the state agency charged with regulating the practice of Psychology pursuant to Section 20.43, Florida Statutes; Chapter 455, Florida Statutes; and Chapter 490, Florida Statutes. Pursuant to the authority of Section 20.43(3)(g), Florida Statutes, the Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance, councils, or boards as appropriate including the issuance of emergency orders of suspension or restriction. . 2. Respondent is, and has been at all time material hereto, a licensed Psychologist in the State of Florida, having been issued license number PY 3824. 3. Respondent's last known address is 7301 North University Drive, Suite 302, Tamarac, Florida 33321-2936. 4. On or about August 13, 1999, Respondent was court appointed to conduct a psychological evaluation of F.C. for a child custody evaluation. 5. | However, it was the Respondent's assistant who conducted the evaluation while the Respondent supervised, observed F.C. and wrote the report. 6. The Respondent failed to indicate in his report that anyone other than himself conducted the evaluation. 7. Therefore, based on the foregoing, Respondent has violated Section 490.009(2)(h) Florida Statutes, through a violation of Rule 64B19-18.004(2)(d), Florida Administrative Code for failing to specify in the report the name of each person who assisted in the administration of the test. WHEREFORE, Petitioner respectfully requests that the Board of Psychology enter an order imposing one or more of the following penalties: revocation or suspension of the Respondent's license, restriction of the Respondent's practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, and/or any other relief that the Board deems appropriate. SIGNED this DOW day of 7! Ak , 2000. Robert G. Brooks, M.D. foo ee ts Secretary, Department of Health i= ad is e) y, Dep Esa] DEPARTMENT OF HEALTH CLERK : By: Nancy Snurkowski, Chief Attorney DATE -C/L/oo On Behalf of Agency for Health - 7 Care Administration Shannon R. Fleming, Senior Attorney.~$ £ 4 Agency for Health Care Administration General Counsel’s Office-MQA Practitioner Regulation - Legal FS PS P O Box 14229 ESO Tallahassee, Florida 32317-4229 S35 9 "4 (850) 488-1474 ga0 5 PCP: Rivas-Vazquez, Schwartz = & 2 fry S45 DATE: April 25, 2000 a & & to SRF/dja 06/15/2000 2

Docket for Case No: 00-004186PL