STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, BOARD OF ) MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 10-3348PL

) ESTABAN ANTONIO GENAO, M.D., )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was held in this case on September 15, 2010, by video teleconference, with the parties appearing in Miami, Florida, before Patricia M. Hart, a duly- designated Administrative Law Judge of the Division of Administrative Hearings, who presided in Tallahassee, Florida.

APPEARANCES

For Petitioner: Diane K. Kiesling, Esquire

Gavin D. Burgess, Esquire Department of Health

4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399

For Respondent: Estaban Antonio Genao, M.D., pro se

13583 Southwest 183rd Terrance Miami, Florida 33177

STATEMENT OF THE ISSUE

Whether the Respondent committed the violations alleged in the Administrative Complaint dated March 27, 2009, and, if so, the penalty that should be imposed.

PRELIMINARY STATEMENT

In a four-count Administrative Complaint dated March 27, 2009, the Department of Health ("Department") charged Estaban Antonio Genao, M.D., as follows:

1. Count One: The failure to practice medicine with that level of care, skill, and treatment that is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances with respect to his treatment of patient G.M., in violation of

   Section 458.331(1)(t), Florida Statutes (2004);

   
   

2. Count Two: The failure to practice medicine in accordance with the prevailing professional standard of care of care with respect to the treatment of patients S.B., M.C., S.E., M.E., L.G., R.M., G.M., M.S., J.S., J.T., E.T., and J.T.2, in violation of Section 458.331(1)(t), Florida Statutes (2005);

3. Count Three: Inappropriately prescribing and/or administering a legend drug, including a controlled substance, other than in the course of his practice, in violation of Section 458.331(1)(q), Florida Statutes (2005); and

   
   

4. Count Four: The failure to keep legible medical records that justify the course of treatment for patients S.B., M.C., S.E., M.E., L.G., R.M., G.M., M.S., J.S., J.T., E.T., and J.T.2, in violation of Section 458.331(1)(m), Florida Statutes (2005).

Although a request for an administrative hearing involving disputed issues of material fact was not included in the documents transmitted to the Division of Administrative Hearings by the Department, the Department's counsel represented in its transmittal letter that Dr. Genao had requested a hearing and that the matter was being forwarded to the Division of Administrative Hearings for assignment of an administrative law judge. Pursuant to notice, the final hearing was held on September 15, 2010.

At the hearing, the Department presented the testimony

of E. Rawson Griffin, M.D., and Petitioner's Exhibits 1 through

14 were offered and received into evidence. Dr. Genao testified in his own behalf but did not offer any exhibits into evidence. Counsel for the Department requested leave to amend the Administrative Complaint to correct a transposition error. She pointed out that the allegations in paragraphs 71 through 78 erroneously referred to patient M.S.; the Department requested that the references be changed to patient J.S. Counsel for the Department also pointed out that the allegations in

paragraphs 79 through 81 erroneously referred to patient J.S; the Department requested that the references be changed to patient M.S. Dr. Genao had no objection, and the Department's request was granted.

The one-volume transcript of the hearing was filed with the Division of Administrative Hearings on October 1, 2010, and the parties timely filed proposed findings of fact and conclusions of law, which have been considered in the preparation of this Recommended Order.

FINDINGS OF FACT

Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made:1

1. At the times material to this proceeding, the Department was the state agency responsible for the investigation and prosecution of complaints involving physicians licensed to practice medicine in Florida. See § 456.072, Fla. Stat. (2004-2005). At the times material to this proceeding, the Board of Medicine ("Board") was the entity responsible for regulating the practice of medicine and for imposing penalties on physicians found to have violated the provisions of

   Section 458.331(1), Florida Statutes (2004-2005).

   
   

   See § 458.331(2), Fla. Stat. (2004-2005).

   
   

2. At the times material to this proceeding, Dr. Genao was a physician licensed to practice medicine in Florida, having been issued license number ME 58604.

3. Dr. Genao practiced in the field of pediatric medicine, and he was board-certified in pediatrics. His practice was located at 13059 Southwest 112th Street, Miami, Florida.

4. In or about 2005, Dr. Genao became aware that so-called "infusion centers" were opening in Miami-Dade and Broward Counties, Florida, to treat patients who had been diagnosed with HIV/AIDS and who required injections and infusion treatments for HIV/AIDS-related conditions. Dr. Genao visited one such center and observed a physician, a Dr. Fauler, as he provided infusion treatments to HIV/AIDS patients. Dr. Genao believed that

   Dr. Fauler's treatment of the HIV/AIDS patients was appropriate.

   
   

5. Dr. Genao had training in intravenous treatments, and, after observing Dr. Fauler and working for a time under

   Dr. Fauler's supervision, Dr. Genao considered himself ready to begin treating HIV/AIDS patients in an "infusion center" that he intended to operate out of the office housing his pediatric practice. By his own admission, Dr. Genao had no formal training or experience treating patients with HIV/AIDS.

6. Dr. Genao's first patient was G.M., whom Dr. Genao treated for HIV/AIDS-related conditions between May 25, 2005, and June 20, 2005.

   
   

7. At the end of July, Dr. Genao was approached by two men who offered to bring him HIV/AIDS patients for injections and infusion treatment for HIV/AIDS-related conditions. Dr. Genao felt he was competent to treat HIV/AIDS patients with infusion therapy, and he signed a contract with the two men in which he agreed to see HIV/AIDS patients in exchange for a salary.

   Dr. Genao assumed that the patients he would see also had primary care physicians who were treating the patients for HIV/AIDS.

8. In mid-August, 2005, Dr. Genao began to see HIV/AIDS patients regularly at his office in the mornings, before his pediatric patients arrived. Between August 15, 2005, and October 14, 2005, Dr. Genao treated 11 HIV/AIDS patients.

   Dr. Genao diagnosed these patients as suffering from conditions associated with HIV/AIDS, such as neuropathy; neutropenia; thrombocytopenia; and diarrhea. Dr. Genao ordered various treatments for these patients, including intramuscular injections of drugs such as Sandostatin and infusion of such drugs as Rituxan, Neupogen, and Neumega.

9. Shortly after he began treating these HIV/AIDS patients, Dr. Genao began to question the appropriateness of the modes of treatment he had observed at Dr. Fauler's infusion center and to feel uncomfortable about treating the HIV/AIDS patients. He sought training at Jackson Memorial Hospital in

   
   

   Miami, Florida, and attended training sessions during which he observed a physician who specialized in the treatment of HIV/AIDS patients and who ran the HIV/AIDS clinic at Jackson Memorial Hospital. Dr. Genao attended these training sessions three days per week for two weeks.

10. Dr. Genao realized that the treatment given by the physician at Jackson Memorial Hospital was completely different from the treatment he was providing the HIV/AIDS patients in his office. Dr. Genao also realized that the patients he was treating for HIV/AIDS-related conditions were not being treated for the underlying HIV/AIDS by primary care doctors.

11. Dr. Genao decided to stop treating the HIV/AIDS patients that he was seeing pursuant to the contract with the two men, who were not physicians. When he told the men that he wanted to renege on the agreement, they told Dr. Genao that he had to continue treating the HIV/AIDS patients until they could find another physician to provide them treatment. Dr. Genao felt threatened by the men, and he continued to treat the patients until on or about October 14, 2005.

12. During the time that Dr. Genao treated the HIV/AIDS patients brought to him by the two men, the men prepared all of the bills to be submitted to Medicare and/or Medicaid.

    Dr. Genao signed each bill in the large stacks of bills presented to him without reviewing any of them.

    
    

13. The Department's expert testified at length about the treatment that Dr. Genao provided to the 12 HIV/AIDS patients he had treated, and the expert enumerated the ways in which

    Dr. Genao had violated the standard of care in their diagnosis and treatment. In his responses to the Department's request for admissions, Dr. Genao admitted that he failed to diagnose and treat these patients properly.2 Furthermore, in his testimony at the final hearing, Dr. Genao admitted that his treatment of these patients fell below the standard of care, and he agreed with the Department's expert that he misused some of the drugs he prescribed for the patients, failed to follow through with necessary treatment for these patients, and neglected their care.3

14. Based on the patients' medical records, on testimony of the Department's expert, and on Dr. Genao's admissions and testimony, the ways in which Dr. Genao failed to meet the applicable standard of care in treating the 12 HIV/AIDS patients may be grouped into categories and summarized as follows:

    1. Dr. Genao treated patients S.B. and J.S. for diarrhea with intramuscular injections of Sandostatin; Sandostatin is a medication that is not appropriate for the treatment diarrhea but is used to treat the very rare disease, acromegaly.

    2. Dr. Genao treated patients S.B. and G.M. for thrombocytopenia with multiple intravenous infusions of Rituxan,

       
       

       a drug that is not appropriate for the treatment of thrombocytopenia, which is a bleeding disorder caused by an abnormally low level of platelets. Rituxan is used to treat lymphoma and rheumatoid arthritis, and it is a very expensive and dangerous drug that can sometimes cause death.

    3. Dr. Genao failed to follow-up with diagnoses and treatment for seriously abnormal values that showed up in the results of blood work ordered by Dr. Genao for patients S.B., S.E., L.G., G.M., J.S., and J.T.

    4. Dr. Genao failed to refer patients S.B., S.E., M.E., L.G., J.T., E.T., and J.T. 2 to specialists for evaluation when such evaluation was indicted by the patients' complaints and symptoms.

    5. Dr. Genao failed to notify patient M.E., whom Dr. Genao saw only once, of abnormal blood test results that should have been evaluated and treated.

    6. Dr. Genao failed to revise his treatment of patients S.E., L.G., J.T., and E.T. when it became clear that there had been no improvement in the conditions of the patients after Dr. Genao had treated them for a month or more.

    7. Dr. Genao administered Neupogen to patients E.T. and

       
       

       J.T. 2 when treatment with this drug, which is used primarily to treat patients with a critically low white blood cell count

       
       

       resulting from chemotherapy, was not indicated by the results of blood tests.

    8. Dr. Genao failed to diagnose accurately and/or timely conditions that were indicated by the complaints, symptoms, and results of blood tests for patients S.B., S.E., M.E., L.G., G.M. J.S., J.T., E.T. and J.T. 2.

15. By his own admission, Dr. Genao failed to keep appropriate medical records of the treatment of these

    12 patients. Dr. Genao's medical records were often illegible4; there were no medical records for patients M.C. and R.M., just billing records; and the medical records were incomplete and generally failed to justify the course of treatment for patients S.B., S.E., M.E., L.G., G.M., J.S., M.S., J.T., E.T., and

    J.T. 2.

    
    

    Summary and findings of ultimate fact

    
    

16. The evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao committed medical malpractice because he did not provide to the 12 HIV/AIDS patients he treated the level of treatment, skill, and care that would be found acceptable by a reasonable prudent similar physician under similar circumstances.

17. Even though the evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is

    
    

    sufficient to support a finding that Dr. Genao prescribed and administered Rituxan, Sandostatin, and Neupogen inappropriately and in excessive quantities for some of his HIV/AIDS patients, the evidence is not sufficient to establish that this conduct occurred outside Dr. Genao's professional practice.

18. The evidence presented by the Department, together with the admissions and testimony of Dr. Genao, is sufficient to support a finding that Dr. Genao failed to keep medical records that were legible and complete and that justified the treatment that he provided his HIV/AIDS patients.

    CONCLUSIONS OF LAW

    
    

19. The Division of Administrative Hearings has jurisdiction over the subject matter of this proceeding and of the parties thereto pursuant to Sections 120.569 and 120.57(1), Florida Statutes (2010).

20. In its Administrative Complaint, the Department charged Dr. Genao in Count One with having committed medical malpractice, in violation of Section 458.331(1)(t), Florida Statutes (2004), with respect to his treatment of patient G.M.; in Count Two with having committed medical malpractice, in violation of Section 458.331(1)(t), Florida Statutes (2005), with respect to his treatment of patients S.B., M.C., S.E., M.E., L.G., R.M., G.M., J.S., M.S., J.T., E.T., and J.T. 2; in Count Three with having inappropriately prescribed and

    
    

    administered legend drugs, in violation of

    
    

    Section 458.331(1)(q), Florida Statutes (2005), with respect to patients G.M., S.B., M.C., M.S., E.T., and J.T. 2; and in Count Four with having failed to keep adequate and legible medical records, in violation of Section 458.331(1)(m), Florida Statutes (2005), with respect to patients S.B., M.C., S.E., M.E., L.G.,

    R.M., G.M., M.S., J.S., J.T., E.T., and J.T. 2.

    
    

21. Section 458.331(1), Florida Statutes (2004), authorized the Board to impose penalties ranging from the issuance of a letter of concern to revocation of a physician's license to practice medicine in Florida and/or the imposition of an administrative fine if a physician committed one or more acts specified therein. Section 458.331(1), Florida Statutes (2004), provided that the following acts pertinent to this proceeding constituted grounds for disciplinary action by the Board:

    (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, "repeated malpractice" includes, but is not limited to, three or more claims for medical malpractice within the previous 5-year period resulting in indemnities being paid in excess of $50,000 each to the claimant in a judgment or settlement and which incidents

    involved negligent conduct by the physician. 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. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross malpractice," "repeated malpractice," or "failure to practice medicine with that level of care, skill, and treatment which is recognized as being acceptable under similar conditions and circumstances," or any combination thereof, and any publication by the board must so specify.

    
    

22. Section 458.331(1), Florida Statutes (2005), authorized the Board to impose penalties ranging from the issuance of a letter of concern to revocation of a physician's license to practice medicine in Florida and/or the imposition of an administrative fine if a physician committed one or more acts specified therein. Section 458.331(1), Florida Statutes (2005), provided that the following acts pertinent to this proceeding constituted grounds for disciplinary action by the Board:

    (m) Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or

    
    

    billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations.

    
    

    * * *

    
    

    (q) Prescribing, dispensing, administering, mixing, or otherwise preparing a legend drug, including any controlled substance, other than in the course of the physician’s professional practice. For the purposes of this paragraph, it shall be legally presumed that prescribing, dispensing, administering, mixing, or otherwise preparing legend drugs, including all controlled substances, inappropriately or in excessive or inappropriate quantities is not in the best interest of the patient and is not in the course of the physician’s professional practice, without regard to his or her intent.

    
    

    * * *

    
    

    (t) Notwithstanding s. 456.072(2) but as specified in s. 456.50(2):

    
    

    1. Committing medical malpractice as defined in s. 456.50. The board shall give great weight to the provisions of s. 766.102 when enforcing this paragraph.

       Medical malpractice shall not be construed to require more than one instance, event, or act.

       
       

    2. Committing gross medical malpractice.

       
       

    3. Committing repeated medical malpractice as defined in s. 456.50. A person found by the board to have committed repeated medical malpractice based on s. 456.50 may not be licensed or continue to be licensed by this

    
    

    state to provide health care services as a medical doctor in this state.

    
    

    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. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify.

    
    

23. Section 456.50(1)(g), Florida Statutes (2005), defines medical malpractice in pertinent part as follows: "Medical malpractice" means the failure to practice medicine in accordance with the level of care, skill, and treatment recognized in general law related to health care licensure." Section 766.102(1), Florida Statutes (2005), provides in pertinent part: "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."

24. The Department seeks to impose penalties against

    
    

    Dr. Genao that include suspension or revocation of his license and/or the imposition of an administrative fine. Therefore, the Department has the burden of proving the violations alleged in

    
    

    the Administrative Complaint by clear and convincing evidence. Department of Banking and Finance, Division of Securities and

    Investor Protection v. Osborne Stern and Co.,	670	So. 2d 932
    (Fla. 1996); Ferris v. Turlington, 510 So. 2d	292	(Fla. 1987);
    Pou v. Department of Insurance and Treasurer,	707	So. 2d 941

    
    

    (Fla. 3d DCA 1998); and Section 120.57(1)(j), Florida Statutes (2009)("Findings of fact shall be based on a preponderance of the evidence, except in penal or licensure disciplinary proceedings or except as otherwise provided by statute.").

25. "Clear and convincing" evidence was described by the court in Evans Packing Co. v. Department of Agriculture and Consumer Services, 550 So. 2d 112, 116, n. 5 (Fla. 1st DCA 1989), as follows:

    . . . [C]lear and convincing evidence requires that the evidence must be found to be credible; the facts to which the witnesses testify must be distinctly remembered; the evidence must be precise and explicit and the witnesses must be lacking in confusion as to the facts in issue. The evidence must be of such weight that it produces in the mind of the trier of fact the 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).

    
    

    See also In re Graziano, 696 So. 2d 744 (Fla. 1997); In re

    
    

    Davey, 645 So. 2d 398 (Fla. 1994); and Walker v. Florida

    
    

    Department of Business and Professional Regulation, 705 So. 2d 652 (Fla. 5th DCA 1998)(Sharp, J., dissenting).

26. Based on the findings of fact herein, the Department has proven by clear and convincing evidence that Dr. Genao's care of the 12 HIV/AIDS patients he treated between May and October of 2005 fell below the level of care, skill, and treatment which would have been recognized as acceptable and appropriate by a reasonably prudent similar physician in similar circumstances. The Department has, therefore, met its burden of proving by clear and convincing evidence that Dr. Genao committed medical malpractice in violation of

    Section 458.331(1)(t), Florida Statutes (2004 and 2005).5

    
    

27. The Department has proven by clear and convincing evidence that Dr. Genao inappropriately prescribed and administered to some of his HIV/AIDS patients Rituxan, Sandostatin, and Neupogen, all of which are legend, or prescription, drugs.6 In its Proposed Recommended Order, the Department has categorized these actions as both medical malpractice in violation of Section 458.331(1)(t), Florida Statutes (2004 and 2005), and as prescribing and administering legend drugs "other than in the course of [Dr. Genao's] professional practice," in violation of Section 458.331(1)(q), Florida Statutes (2004 and 2005).

    
    

28. Section 458.331(1)(q), Florida Statutes (2004 and 2005), includes a legal presumption that a physician's prescribing or administering legend drugs "inappropriately or in excessive or inappropriate quantities" is "not in the course of the physician's professional practice." The Department cannot, however, as it does here, seek to punish the identical conduct as both being within the practice of medicine and outside the practice of medicine. If the legislature did not consider the acts that constitute a violation of Section 458.331(1)(q), Florida Statutes (2004 and 2005), to be separate and distinct from, and more serious than, the negligent acts that constitute medical malpractice pursuant to Section 458.331(1)(t), Florida Statutes (2004 and 2005), there would be no need for it to identify separate violations.

29. Under the circumstances of this case, where Dr. Genao has been found guilty of medical malpractice for, among other things, inappropriately prescribing and administering legend drugs, the Department may not use the legal presumption in Section 458.331(1)(q), Florida Statutes (2004 and 2005), as the sole basis for a violation of that section by Dr. Genao. It is, therefore, concluded that the Department has failed to prove by clear and convincing evidence that Dr. Genao violated

    Section 458.331(1)(q), Florida Statutes (2004 and 2005).

    
    

30. Based on the findings of fact herein, the Department has proven by clear and convincing evidence that Dr. Genao violated Section 458.331(1)(t), Florida Statutes (2004 and 2005), by failing to maintain legible and adequate medical records pertaining to all twelve patients included in the Administrative Complaint.

31. Florida Administrative Code Rule 64B8-8.001 sets forth the range of penalties that may be imposed for violations specified in Section 458.331(1), Florida Statutes. Florida Administrative Code Rule 64B8-8.001, provides that the penalty for a violation of Section 458.331(1)(m), Florida Statutes, ranges from a reprimand to two years' probation, community service, and imposition of an administrative fine of $1,000.00 to $10,000.00; and that the penalty for a violation of

    Section 458.331(1)(t), Florida Statutes, ranges from one year's probation to revocation, and imposition of an administrative fine of $1,000.00 to $10,000.00.

32. There is no need to consider the aggravating and mitigating factors set forth in Florida Administrative Code Rule 64B8-8.001(3) because the recommended penalty does not deviate from the range of penalties specified in Florida Administrative Code Rule 64B8-8.001(2).

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Medicine enter a final order finding that Estaban Antonio Genao, M.D., violated

Section 458.331(1)(m) and (t), Florida Statutes (2004 and 2005), and revoking the license of Estaban Antonio Genao, M.D., to practice medicine in the State of Florida.

DONE AND ENTERED this 30th day of November, 2010, in Tallahassee, Leon County, Florida.

S

Patricia M. Hart Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 30th day of November, 2010.

ENDNOTES

1/ The undersigned has also used information provided by

Dr. Genao in the post-hearing written statement he filed with the Division of Administrative Hearings on October 4, 2010, to supplement his testimony at hearing.

2/ Petitioner's Exhibit 13.

3/ See Transcript of the proceedings at pages 151 through 153.

4/ The medical records maintained by Dr. Genao were generally handwritten by him. The legibility of these handwritten records was somewhat compromised because Dr. Genao has for some years suffered from rheumatoid arthritis and it is difficult for him to write. He could, however, have chosen an alternative means of preserving his patient records.

5/ Because the provisions of Section 458.331(1)(t), Florida Statutes (2005), are substantially similar to those of Section 458.331(1)(t), Florida Statutes (2004), Dr. Genao's treatment of patient G.M. will not be treated separately.

6/ Section 465.003(8), Florida Statutes (2005), provides in pertinent part: "Medicinal drugs" or "drugs" means those substances or preparations commonly known as "prescription" or "legend" drugs which are required by federal or state law to be dispensed only on a prescription, "

COPIES FURNISHED:

Diane K. Kiesling, Esquire Department of Health

4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399

Estaban Antonio Genao, M.D. 13583 Southwest 183rd Terrance Miami, Florida 33177

R. S. Power, Agency Clerk Department of Health

4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701

E. Renee Alsobrook, Acting General Counsel Department of Health

4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399 1701

Larry McPherson, Jr., Executive Director Board of Medicine

Department of Health

4052 Bald Cypress Way, Bin C03 Tallahassee, Florida 32399-1701

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this recommended order. Any exceptions to this recommended order should be filed with the agency that will issue the final order in this case.

Docket for Case No: 10-003348PL

Orders for Case No: 10-003348PL