Commonwealth of Massachusetts Board of Registration in Medicine Ton West Street, 3rd Floor, Boston, MA 02311 (617) 727-3086 bupsfwww-massmedboard.org Physician Registration Renewal Application Before proceeding, please read dhe instrud ced copies for eredentaling and other pu _Excen envelope & weeks before your renewal + Remit 250.00 for renewal fee. + Add late fee of $25.00, if necessary -] Endose check with coupon in BLUE envelope. Please review carefully the follo ind completeness. Make any corrections or FEDACTED Copy alterations as required FEDACT } 1. Current Stat: active Registration No.76366 Renewal Dae: g9psront {yoy want to change your current status, please check aus ofthe following boxes to indicate your new status: (Check only one) ree Ci Retiring. (see instructions) Diitaactive (see instructions) Ce not wish to renew ease make correction + pin 2. Other Name(s), itany, under which you wete Mccnsed: pesos terre e cue ie css [Otter Namely 5 3. A) Mailing/Business Adres: aiing Addie JONA'BiaN'S FAILS eigen 133 BROOKLINE AVE. BOSTON, MA 02215 zip Tasiness Adee 1B) Home Address: CityrTown: zip:__ Country Business Telephone: (6/9) _wzp= 197 Ciy/Town: a Zig. Country: Home seiephone! Home Phone e (617)267-1622 Business Phone: PLEASE NOTE: No P.O. Box addresses for home or business addresses. 7, Current American ard of Medical Specialties Certification (See Tabie 2) 4, Dae of Binh: Sex gy wren ba esse 8. Drag License Names, on: 5. a) Name of Medical School: a) Federal (DEA): 3) Mosse by VUREALIREIY Shoot Medi oe, 4s. | 9. a) Oke sais where you re now lias practice (ABBE) ee ian cesar 6. Specialty Code(s) (See Table 1) ~ a ar on Week in Mass, 6 Shoes whee yon were pevionsly ese Ab OBG 0 Obstetries and Gynecology: fee mI = a o 10, Curent health care facilities at which you have completed the credentialing process for the provision of patient care. (Supply the codes from Table 3 and place a check inark next to those health care facilities where vou have admitting privileges (AP), Next to eu facility, write the approximate percentage of patient care hours that you provide in exch facility) Facility Code: ? 2. vin 3.0 % Facility Code:___/__ (AP) _Y% Facility Code: Facility Code: red Eee io 9 Code: {__(AP)___% Facility ou 11999, prt nach DV Are SD ale ves Hedltral tears te SI Sea ee geePRINT YOUR LAST NAME: _ FEZ > __ LICENSE NUMBER: 76366 11. My medica! malpractice insurance is covered by a) (@Y/Insurance Carrier} [) Lewer of Credit Name of Insurer, Lowtdied Ru papery of VEATRA ately, indicate as follows: 1 am registering with Active status but | am no! covered by medical malpractice insurance because {am (check one) a) C1) Not involved in direcVindirect patient care in Massachusetts b) [] Otherwise exempt ee _ 12. Are you ctenly in pow gaat wining program a Mabachsots a resident or cinial flow? ebeck one) vex TKS 13. A. What is your principal work setting? (See Table 4) 2 _O B. Care of patient in Massachusets (ce insteton bookie 1) Average weekly hours involved in: a)outpatient are. “3 _hrafwk b) inpatient care 24 bes 2) What is the approximate percentage of your patient care hours in primary care? 20% By = LEFER ONLY T‘ ‘wo. ARS 14, CLAIMS MADE: Has any medical malpractice claim been made against you that has not yet becn finally settled or adjudicated, whether or not a lawsuit was filed in relation to the claim? 1 15, CLAIMS RESOLVED: Has any medical malpractice cli that has been made aginst you been settled, ‘adjudicated, or otherwite resolved, whether or not a lawsuit was filed in relation to the claim? | 16. Has any lawsuit, oder dhan a medical malpractice sui, which related 1o your competency to practice medicine, or your profesional condect inthe practice of medicine bee filed egains you or been seed, adjudicated or otherwise resolved? | 17. Have you been charged with any criminal offense ober hana minor alc violation? 18, Have you ben charged with or disciplined for any violation of laws, ules, by-laws or standards of practice of any governmental authori, healthcare facili, growp practise or profesional society o association? ' Has your privilege to possess, dispense or prescribe controlled substances been suspended, evoked, denied, ; restacted by, or surrendered fo ay state of federal agency? 20. Have you withdrawn ao application for a medical license or been dened a medical license fr any reason? 1 21, Has any professional liability insurance prover restricted, listed, tenminated, imposed » surcharge or co-payment, or placed any condition related to professional competency or conduct on your coverage or have you voluntarily restricted, limited or erminated your insurance coverage in response to an inquiry by & Beofessional lability insurance provider? 20, CME.CERTIFICATION: Have you completed your CME requizemeats preceding your renewal date? [Ves] No CME Waiver requested (CME waiver form die 30 days prior to date of license expiation) Dlemeesemprion — | See Instructions for CME requirements. Do not submit documentation of your CMEs with your renewa) application. Porsoant to GL. 112,§2, wil eot charge te oF collect frm a Medicare beneficiary more than the Medicare fee schedle amen Porsuant to GL. ¢. 62C, §49A, fo the Dest of my knowledge and belle, have fled all Massachusetts state tax returns and pald al Massachasetts state taxes that are required under law. NOTE: This applies even ifyou reside out-of-state or out of the United States: + Pursuant to GL c. 62C, $ 474, to the best of my knowledge and belief, Iam in compliance with M.G.H.C: 119A relating to withholding and remiting Child Support. . an 5" Purtivant fo GL"e 112, § 1A, Ill Fulfill my obilgation to report abuse or neglect of children as required by GL. e119, § $1 + Thereby certify under the penalties of perjury that alt the information on the Renewal Application and Form R is true. Signature: Pierce pues 217 10, Ww: IN oti re Bos in wr chat idr MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. — 2Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320 Physician Registration Renewal Application Before proceeding, please read the Instruction booklet. * Copy this form and al attachments for your own records; you will need copies for eredentialing and other purposes + Remit $250.00 for renewal fee, + Return renewal application in GREEN envelope, + Add late fee of $28.00, If necessary. + Enclose check with coupon in BLUE envelope Registration No,: 76366 Renewal Date: 99/25/1999 1, Current Stars: 4¢ Ifyou want to change your current status, please indicate below: (Check one). Dactive DpRetiring. (see instructions) Dinactive (see below *) Do Please make corrections (type 2. Other Name(s), if any, under which you were licensed: 3, A) Mailing/Business Address: JONATHAN S FRIEDES ating Naas “Tay Broek tne Bee ekyrtow: “Gs Fen Sate: County: USA B) Home Aditess: Home Phone: Business Phone: 4, A) Date of Birth: Sex M B)SS#: 5. A) Name of Medical School: ale University School of Medicine BY Year Graduated: 1988 cy Desree; MD. 6. Specialty Code(s) (See Table 1) Bde House HE ecoioay ° 7. Curent American Boned of Medical Speciaties Certification (See Table 2) Ly [ Codes> Codes Code: Code: 8, Drug License Numbers, ifame- ; ‘A) Federal (DEA): Weel 'B) Massechusets: 8. A) Other stajes where you are now licensed to pretie ‘Abbr: B) States where you previously were licensed to practice Abbr: HI! Abbr: Abbe: “Hf requesting Inactive status, you agree not to practice medicine, including writing preseriptions, in Massachusetts, 6PRINT NAME AND NUMBER: LastName:__ FREE DES, Registration Number;2¢366_** *"s 10, Current health care facilities at which you have completed the credentialing process forthe provision of patient cate. Supply the codes from Table 3 and place @ check mark next to those health cate facilities where you have admitting privileges (AP). Next to cach facility, write the approximate percentage of patent cate hou that you provide i each facility. Facility Code: 22-1 /_(aP)_23. % Facility Code:___|_(AP)_% Facility Code: Facility Code: ¥ f 7? /__ (AP)A*_% Facllity Code;__/_(AP)_% Facility Code; 1£999, print name(s): ew EEmaland Surg icary 3t ; 11, My medical malpractice insurances covered by &) T)fasurance Carrier b) [] Letter af Credit Name of Insurer: Costell Risk. Tascray Sapp ef Yecaeit- ie, Alternatively, indicate ws follows: Tam registering with Active status but I am not covered by medical malpractice insurance because I am (check one) 4) [Not involved in drecvindirect patient care in Massachusetts b) [1] Otherwise exempe Pleas explain exemption: 12, Are you currently in a post-graduate training program in Massachoscts asa resident or clinical fellow? (chock one) [-) Yea [}o 13. A. Waat is your principal work setting? (See Table 4) _2- {7 B. Care of patients in Massachusetts (se instruction booklet). 1) Average weekly hours involved é a) outpatient care 34 trsiwk b) inpatient care 27 hrs/wk 2) What isthe approximate percentage of your patient care hours in primary care? 2.0% ~ OVESTIONS REFER ONLY TO Al 14, CLAIMS MADE: Has any medical malpractice claim been made against you tat has not yet been finally settled or adjudiceted, wether or nota lawsuit was filed in relation to the claim? 15, CLAIMS RESOLVED: Has any medic malpractice claim that has been made against you been sited, adjudicated, or otherwise resolved, whether or nota lawsuit was filed in eation to the clan? 1 16, Has any lawsuit, other than a medicol malpractice suit, which is related to your competency to practice medicine, or your professional conduct inthe practice of medicine, been filed against you or been setled, adjudicated or | otherwise resolved? 17, Have you been charged with any criminal offense, other than a minor traffic violation? 18, Have you been formally charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of any governmental authority, health care facility, group practice ar professional society or association? | 19, Has your privilege to possess, dispense or prescribe controlled substances been surendered to or suspended, revoked, denied or restricted by any state or federal agency? 20. Have you withdrawn an application fora medical license or been denied a medical license for any reason? 1 21. Has any professional liability insurance provider restricted, limited, terminated, imposed a surcharge ot ‘co-payment, o placed any condition related to professional competency of conduct an your coverage oF have you volunaly restricted, limited or terminated your insurance coverage in response to an inquiry By a professional liability insurance provider? 22, CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date? [Yes [] No (Cl CME Waiver requested (CME waiver form due 30 days priot to date af license expiration) C1) CME exemption ‘See Instructions for CME requirements. Do not submit documentation of your CMEs with your renewal application, (0 GAL e.112,§21 wll ot eharge to or collect frm ¢ Medicare beneficiary more than the Medicare fe schedule amouat © Purs + Purruant to G.L. c,62C, §49A, 0 the best af my knowledge and belief, have filed all Massachusetts stat tax returns and paid al “Massachusetis state taxes that are required under nw. NOTE: This applies even you reslde out-of-state or out of the United States. ‘+ Pursuant to G.L, 6.112, § 1A, {will fll my obligation to report abuse or neglect of ehildron ns roquired by Gula e. 119, §51A. + Thereby certify under the penalties of perjury that all the information ou the Renewal Application and Form R ts true. — Signature:_ oe Date: Gj 20/29 YOU vost SIGN AND INCLUDE PART B, WITH YOUR RENEWAL APPLICATIONI. PHYSICIAN INFORMATION JONATHAN 8 Birst Name Middle Wii ‘Make ciaiiges to nae eve Mass License #76366, License Status... Active, Hichp Kenmore Center 2 Fenway Pleza Boston, MA 02216 USA. (617) 742-1301 ‘Make address corrections here: Make any corrections ta above here: 18083.0000 ERIEDES ane si First Issue Date ,06/28,/22 Hospital Affiliation Brigham & Women’s Hospital Insurance Plan Affiliation ‘Licenses Held in Other States: Hered Pol “Accepting New Patients? ee sung cA Accept Medici? (Please correct as necessary) I, EDUCATION & TRAINING Yele University School of Medicine MD a8 ‘Meiliedt School ~~ Digree Date ‘Miike corecttiis here OVE. iz “Ogte Oniveevitey. of. Colv fornia... San. Froncize.... 2% End, ‘Residency Progretn(s) - Bau. ‘Residency Programis) ‘Siart fees z arasaeccaee Bou. Residency Progra) Sart Ti, SPECIALTY JARD CERTI Primary Specialty: Obstetrics and Gynecology Certifying Board Name: Board of Obstetrics and Gynecology Secondary Specialty: Certifying Board Name: Make any corrections here. Board of Rogistration in Medicine Make any corrections here: Physician Profile18038.0000 IV. BOARD DISCIPLINE Final Decisions and orders issued by the Massachusetts Board of Registration in Medicine. Nature Date Board Action V. HOSPITAL DISCIPLINE Hospital | VI. CRIMINAL CONVICTIONS: ‘The Board of Registration is unable to obtain accurate data for this category atthe present time. ‘This informetion will be Included when the cour. system is fully computerized, Please list any criminal convictions. Include conviction date and nature ‘of complaint i : z Vil. MALPRACTICE fs - No, of Years in Practice: # % /p_ Details of claims paid for Dr, FRIEDES Date Amount Paid 0,000 Basis for Complaint Date ‘Amount Paid Basis for Complaint “~~~ a Date ‘Amount Paid Basis for Complaint : Dine “Amount Paid Bis for Complaint “~~ i Date ‘Amount Paid Basis for Complaint q ao Date “Amount Paid Basis for Complaint VIL. PHYSICIAN HONORS & PEER-REVIEWED PURLICATIONS Please enter any peer-reviewed publications to which you have contributed and any awards for community service or professional recognition you have been given, Awards, Honors Publications Harvecd Pilg Pree Reson arbion Avot ufrs [te é Note: Please return the survey in the enclosed envelope to: Atlantic Associates, Inc.. 8030 South Willow Street, Manchester, NH 03103 Board of Registration in Medicine Physician Profile‘Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1995-1997 Physician Registration Renewal Application Regiswaion No, Stans Fee. RenewalDate Late Pee 6366__actrun_ $250.0 _gesosyas $25.00 Corfecton of Milling Address Malling Address ‘Aaecers (Mailing) JONATHAN § FRIEDES, M.D. Directions: Usfore proceeding, please read the instruction boaklet, Some questions ae optional + Fallure to renew ins timely manner will cause your Heense to lapse and imay affect your ability to practice medicine In the Commonwealth. (See enclosed letter). + Add tate fe If uecessary, + Make acopy of this form and all uttachments for your own records - you wll need copies for credentialing and other purposes. The Board will charge a fee for each copy it provides. « See nstrvetions on detachable coupon at boom ofthis page. Pre-Printed Information Corrections of Pre-Printed Information 1, Other name), fay, under which you were licensed: Name: —_— 2.Business Address: Oto: — a HCHP KENMORE CENTER ine acre eee erence] 2 FENWAY PLAZA BOSTON, MA 02215 3. Date of Birth: Sex: yg ‘Date of Birth (M/D/Y): JL Sex (M/F): Ue le De 9g 729799 Lene Due QD: Sse eee eine Home” Baines re) tt TY - Pall Nane of Media! Scoot Country: 4. Name of Medical School: Yale University School of Medicine YourGduated: Degree (MD/DO) Year Graduated: gg Degree: MD = 2 5. 6) Other ses where you se now Hensod to practice (Abb): _- ee &) Sates where you previously wer licensed to practice (Abbe Gat —_ — — — ‘Code Homapa Wak Man. 4, Specialty Codes) (See Table 2 Bomar Wesk in Mass. Gods Hous per Week in M CBG ner x 0BG 0 Obstetrics and Gynecology | ‘iros, piney: 1 7. Wt you ae curently Ameria Specialty Board verified enter codes: (See Table 2) ote Code: code: OC codes § Drug license mumbes(s) if any: 4) Federal (DEA) Federal (DEA): ) Massachsets Mass: 9. Atv Sta Lam apejingtoberepiterd wih de foowing sane: acmive LY twacrwve + Thereby cert ht rutting Inactive tats Xl ot practce med, lauding wring pescrp ons a MasacustePRINT NAME AND NUMBER: Physician Las Name: ERO EDES _ possvation Number, F666 10, 2) Caren heath cate allie) at which you hve completed te crodentaling proces forte provision of patient eae. Supply he som Tn ge check yh ese as ee poate > Facility Code: 222 L} SA (AP) Facility Code: wm ome mem fan (AP) ——Failty Code: ane / (AP) Factiy Code: LF Fy cary fagtiycais — 1 Ah nots — a) 1£999, print name(s): Ad end Ens lon Suucq tear. _[outepabiest Sac faucliby —t 1) Additional hospitals at which you pou held pivtges and ober health cre facies with which ou Were asointe int pas 2 yas. (See Table 3) Pailty Coe: Facility Code: Facil Coe Facility Code: Fecitity Code: 16999, write name(e: 1isMy medical mals nugrgis covered by (0) Insure Carr LZ ()Lawarof Cad __. apie check on List Insurer: PTO ‘Alernatvely, indicate as follows: Yam registering witk ACTIVE status, but Iam nol covered by medical malpractice insurance because | am. (Check One}: (i) Not involved in dreoyncirect patient care in Massechuset (i) Otnerwise exempt: State how otherwise exempt 12. Are you caenly in a os-sraduni waning program in Masa aresi=nor cial (olow? Yes No I (Chesk ns) 15. a) Whatis your principal wer sauing? (Soe Tables) YO a ¥) Core of paints in Massachuset (Seo instrction hooklet) aera 4) How many hous per typical weck are you curently involved in oudpaent care in Mass? Be hn i How may ou er piel wens you cuenyivoledin ain nein Mas? BEB aah ©) Approximately what percentage of your patient care hours ae in primary care? (See instructions for definition of primsry care) OQ % ‘Questions 14 through 24 refer tothe past two years only. Check ether YES or NO (NOT NjA) to each question. Provide details on Forms R-! and R-2for all YES ancwers (GNUnE PAST TWO YEARS: | MES NO. YE CLAIMS ADI Hs ela sp chin en atch nyt le Sieben chsbe nears tedncmieoaeckee : 15.CLATMS RESOLVED? Huser mates meinen ga yo txn ae stud oars ao ce ae cmicaenoe ees hs pc cc ea WW la Yee aay nak ES a eal cnn pss of mac, at el not ways aie, obs oe seen ose feeiear erect ‘ttre ons larpd wi yin fa ah ase said, este oly cae hp ry nt ele isa prennendesindl makes titel paged ercsecias, «conan en FS pei et im eee thd rei sion dobre RN gear ti larger reel et : do. us witrorn nlite de aoa rm oe 21s ary potion! ait uree pve, a ena or ngs esclugeon ou ever tye nn ae ns mney trace rare no lo eee 22 Haregoe en dghoced wor do os bar «tlc coion wih ning your aly epraicemedchl Biya scl cnet yee eas cela me pci 2 Hej ict inl pat onc a i se : 25. Theveconpd ny CME rausemann he wo yu rcetng nyo de Yor LZ Na wane eas Nevcuane pops angen seston toca Teoqentas wae oo eno sop Wee Roa, Te svt bo grad by i Border po Tae wb trowel Se inroas fr ME raqatenena, Dose deh drsannaian st you CMs eit you mova oleace Ppemsceanlc das aiemtaedpols sarneltvaro ay eiesaie acca + Paras 062 G ACen wry ree ports rer nob yng a oe ‘nae tnd el Manhood pad a Musee stats tar rune ares NG Teepe Milton alot oneal the Unica See 7 Feemaat oe lhce thee Ast my ely ts A my gc rept sha or eta Ar regu g neunoean + Hert einer hpi an peas f peor al formation on Ms form nd Forms nd Ree Signo: CO FD. ower 913 PS, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE Fee -$300.00 to be submitted For Office Use 2 Application # : 130d czxtiewet Daeot ise ‘SWORN STATEMENT 7 Cs pate s/eyf Pe GB TYnme Towrrn ay storie, FREED Addo . Fa ; : CE PPome or Bien i Pisses Sree Sereeeee eco cr Placeof Binh Yew York C4), WX HEE 7 (Nameon Birth Certificate TOwHan” stmuer FRM! Phoned pee g Pre-Medical Education ‘Medical Education Princeton OQaiverin ty School “Yale University Selw! of Hediene rears tended (72 %~ 17% Years Auended 783" /2 99 ss ‘\ Postgraduate Education & Hospital Appointments from graduation from 11 \Medical school to the present tine, Place Position Dates Vnivereity of Galidieria, Sun Primero (VS) ater fra [et fr f¥ CSE Render ON fb fr~ af) oat puted) Is this your first full license? VO xf applicable, please List all ates vhere your_are or have. : Cole Gini GO6UPY? cop WY30/'T3_~ Hawaii HE _ 265 (ery 3/02) Other names under which you have been licensed: Mone. List Specialty Boards by which you are certified: Myx REASON APPLYING FOR A MA LICENSE wil be wortiay or Herued Conmnty Health Dog Anticipated starting dave if yeu have position pending MR Massachusetts: %/ 7/71 ge of address wust be submitted to the Board of icine in writing. Please include effective dates he Wo Finan — A. a pate: & /2y /'% SYGIYAURS oF AEPLICHNTPRINT NAME AND NUMBER: PiysicintastName: FF PEEDES Resiszatn Number: 26 266 fe eee aceon eee nae eee eed « Thereby certty that if requesting Inactive status, {will not practice medicine, including writing prescriptions in Massachusetts. 11. My medial nalts insane reed by @) INSURANCE CARRIER _U/or () LETTER OF CREDIT___ tapi, chk one. Liateswer Qf € RICO Atenas nda ols Ta egg Wis ACTIVE ssa a cove ysl malpniza waa ones Tae (Chock Ow (NOT INVOLVED IN DIRECTINDIRECT PATIENT CAREIN MASS: GDOTHERWISEEXEMPT. eee 12, Curent Health Care Fairy Affiisons, Supply the codes fom Table 4 and place a check mark next othote fe whee you have ‘emitting privileges (AP). wa 97 Faclty Code: 22.1} (a>) Factiy Code: 2 PF ) cap) Festiy Code: _____/ ca) Facility Code: 7} __ (ab) Facility Code: | (AP) Pacility Code: (AP) w999.pinnenies Med Eoy'eed Suogicass ~ (Delpebent forge Pectieyes) ‘Akvona hoxptals a which you previouly held privilege and oer heal are actes with whigh you were sesociie inthe past 2 yeas, (See Table 4 Facility Code: 22 B Facility Codes Facility Cove: Facility Code: _.____. Faility Code: 1999, write name(s) 18 Aveyoueuredyin ouput ining popu in MA st aroete lal flow? Ye. No_'~ (Ck en) 14 5) What is your principal work seuing? (Soe Tables) 4 'b) Care of patients in Massachuseats (MA) (See instruction booklet.) - i) How may hous per pial weck we you carey involved in oupatin caren MAT 25 trek in MA i) low any Roars er plea! week are you caret involved sigan oxen MA? SLOT aca MA (Questions 15 through 23 refer toshe wast two veurs only, Chock cither YES or NO (NOT NIA) to each question. Provide details on Porm 15A forall YES answers. Refer tote insinuction booklet for additional information, Tasos [Ermensrive vers] us M0 15. Has any medical malpractice claim been made against you, whether or not lawsuit was files in elation to the ei 16, Have you been charged with any criminal offense other than s minor taf violation? 17 Hv you aly ben charged wit cpt aay won of abn of ai ny ‘governmental authority health eare Facility, group practice or professional society or association? 18. Has your privilege to possess, dispense or prescribe controled substances been surendored to or suspended, revoked, denied or restricted by any stale or federal agency? ase. 7 19. Have you withdrawn en application for a medical license or been denied a medical licens for any reason. 20, Have you had eny mental illness which has impaired your ability ro practice medicine or to furction as x student of medicine? 21. Have you had an organic illness which has impaired your ability 1 practice medicine oro function asa student of medicine? 22, Are you now, or have you been inthe past wo years, dependent upon alcohol or drags? 23, Has any professional lablty insurance provider resiciod, limited, terminated or imposed u surcharge on your coverage. + Pursuant to G.L. c. 142, sec. 2, I will not charge to or collect from a Medicare beneficlary more than the Medicare reasonable charges. + Parsuant to G.L. c.62C, see. 49A, I hereby certify under the penalties of perjury that, tothe best of my knowledge and belle, I have ‘led all Massachusetts state tax returns and pald all Massachusetts state taxes that are required under law. NOTE: This applies even Ifyou reside out-of-state or out of the country. + Thereby certiy that Iwill fulfll my obligation to report abuse or neglect of children pursuant to G.L.c.119, see. SIA, + Thereby certify under the penalties of perjury that all Information on this form and Form 15A is true. Signe: pa Fick pues S19 123Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street, 3rd Floor Boston, Massachusetts 02111 1993-1995 Physician Registration Renewal Application ‘Sus egisation No ‘Malling Adress: ioe FRIEDES? Correction of Malling Adress: ‘Ares (Mailing: Gig fiom: State: Country Code (See Table 1): Directions: Staple check to bottom of form. Add late Fe i necessary. iz + Questions 1-8 include taformation from Board files, Please correct ax necessary in Ue boxes For Ofis i Only ‘rovided on the ight hand side ofthe page. mR. AUG 2 0 1993 «Before procceding, leate read te instruction booklet. Some question? + Make a copy ofthis form und all attuchments for your own recards for credentialing and cher purposes. The Board will charge & fee foreach copy it provides. + Enclose the $250.00 renewal fee by means ofa certified check, money exder or persoul check mle payable to the Commonwealth of Massachusetts ate optional. you will need copies Pre-Printed Information 1, Other name(s), if any, under which you were lensed: 2. a) Adress (Home): ) Address (Business) 3. Date of Bit: * sex: 9) Lie. Issue Date: Ja / 29/92 88H: ‘Telephone Number: Home 44, Name of Medica} School Yate University dcnoul of Feaicine ‘Year Gradunted: Degree: MU 5. a) Other sates where you are now licensed to practice (Abbr): 1) States where you previoutly were licensed ta practice (Abbr): Specialty Code(s) (See Table 2): Code _Hours per Week in Mass. Code: Code: pI you previously were American Specialty Board certified, but are-no longer, please enter codes of prior cerification: (Soe Table 3) Code: Code: 18, Drug License Number(e, if any: a) Federal (DEA) by State (MA) ) Ie you ars curently American Specialty Board Cetitied, enter Codes: (See Table 3) Name: ‘Address (Home) CityrTown: ‘State Zi Conciry Coxe 1999 print Counny ‘Address @usinagy UCHE_hennasit Cee 3 Pracey Depa | Ciyftowns Bowie, eben Conuniry Code? 11999 print Coury | Datcof Birth (M/D/Y), LL Sox (MF Lic Issue Date (M/D/Y); LSS ‘Telephone Number Horn: e_ Pisincas: (iva) 921 = HL Full Name of Medical School Year Graduated Degree (DIDO): CAS ees ae Code ous pev Wok in Mass OB 6 ze 60S, prt spociay: Code: eae Code: Code: Federal (DEA - State (MAY: — 9. J have completed my CME requirements in de two years preceding my renewal date: Yes No, waives requexted ‘You must il out a keparaie Waiver Form. ‘he waiver must be granted (CME requirements. Do not submit documentation of your CMEs with yur renowal spplication, EN by the Board before your licenue wil ta ronewed, Soe instructions fota Towethen $2 Friel, , ef 3 FORM G “Instructions: This form must be completed and signed by the Director of your internship or residency training program. If you had postgraduate training in more than one program, this form may be duplicated. Upon the Board's address below. t, Jarnes Gavin, ro. _,_ Resideneg thogvarn Oitvelse Name Title hereby certify that _Vusva Mica S irwdey has served -/ year(s) of post-graduate training as a Resident in 0 /6« sites — ° Sis at University al Cali bor pia. » Sar Francasco_. CB : Hospital City ‘State This program is _““ is not approved by the ACGME or the RRC. Dr. FRiedes participated in this program from Veewe- _ 198% vo Jécoce. _» £992~ and was issued V* was not —vonth —" “Year Month Year issued a certificate as proof of completion of said training. (If not issued a certificate, please explain.) HB Ce ct Acale eth he issegk oe Senne I further certify that at the time of completion of the above training, this physician was, to the best of my knowledge, competent to practice medicine and there was no disciplinary action outstanding or pending Mette cits gnature of Director sy involving him or her. 8 fox. Date Hospital Seal RETURN THTS FORM DIRECTLY TO: COMMONWEALTH OF MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE, TEN WEST STREET, 3RD FLOOR, BOSTON, MASSACHUSETTS 02111Commonwealth of Massachusetts Board of Registration in Medicine eon e Ten West Street Boston, Massachusetts 02111 (617) 727-3086 one geo ALEXANDER F FLEMING ‘An Aganey within tho Executive Otice of Consumer Aas and Busioass Reguiation VERIFICATION OF PREMEDICAL AND MEDICAL INSTRUCTION AND GRADUATION INSTRUCTIONS TO THE DEAN OR DESIGNATED OFFICIAL OF MEDICAL SCHOOL Please complete this form in full and return it_DIRECTLY TO THE This Verification cannot be accepted nor can a license be issued to the applicant unless you send this form directly to the Board of Registration in Medicine, Thank you for your cooperation. I CERTIFY THAT _TOWATHAM StaUVEL ERT EDES CREDITABLY NAME OF APPLICANT COMPLETED AT LEAST TWO YEARS OF A PREMEDICAL COURSE INCLUDING PHYSICS, BIOLOGY, INORGANIC AND ORGANIC CHEMISTRY AT: Princeton University, Princeton, NI fui WAME AND LOCATION OF UNDERGRADUATE EDUCATIONAL INSTITUTION NAME AND LOCATION OF SECOND UNDERGRADUATE INSTITUTION (IF APPLICABLE) for admission to: Yale University School of Medicine WANE OF MEDICAL SCHOOL New Haven, CT USA LOCATION OF ‘CITY, STATE, COUNTRY) 1 FURTHER CERTIFY THAT. Jonathan Samuel Friedes WAHE OF APPLICANT HAS COMPLETED AND ATTENDED FOR 4 __ ACADEMIC YEARS OF INSTRUCTION, NUMBER OF NOT LESS THAN THIRTY TWO WEEKS IN EACH ACADEMIC YEAR AT:___Yale University School of Medicine NAME OF MEDICAL SCHOOL FORM E CONTINUED ON NEXT PAGECommonwealth of Massachusetts Board of Registration in Medicine Ten West Street Boston, Massachusetts 02111 (617) 727-3086 FORM E ConrrNuED INES PATEL, MO. [ALEXANDER F. FLEMING. ECVE ocTON ‘An Agency within the Executive Otoa of Conaumar Aare and Business Reguiatlon NAME OF APPLICANT_“VOWATHAW SamUEL PREEDES YO MEDICAL SCHOOL: Give exact dates of instruction, including month, day of month and year for each year to show the number of weeks, excluding vacations, in each year. FROM:_09 08 83 to: _05 25, 8% HONTH DAY YEAR “MONTH DAY YEAR FROM: 09 10 84 ro: _ 05 03 85 WONTH DAY "YEAR NONTH” "DAY YEAR FROM: _07 08 85 To: _06 22 86 WONT DAY YEAR NONTH——DAY YEAR, see below PROM: 07 07 86% 206 21 87 MONTH "DAY YEAR HONTH—DaAY"_YEAR FROM: _07 06 87___T0:_05 27 8 MONTH —"~DAY_YEAR HON av" Year. FROM: Tor . NONTH DAY _YEAR WONT YEAR FROM: i" mo: MONTH "DAY "YEAR WONT DAY YEAR “received a fellowship from the, American Heart.. Association (CT) to do research for this academie year AND HAS RECEIVED/WILL RECEIVE A DEGREEE OF_M.D. 19__ 88 : f tule. 3 4d ‘OR DESIGNATED OFFICIAL Gynthia Andrien, Registrar fee NAME AND TITLE (PLEASE TYPE OR PRINT) ON___May 30, SCHOOL SEAL DATE: _ 06/04/92Commonwealth of Massachusetts Board of Registration in Medic Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext, 320 4 i / q Physician Registration Renewal Application Before proceeding, please read the instruction booklet. + Copy this form and all atachments for your awn records; you will need copies for eredentiling and other purposes. “The Board will charge a fee for each copy. + Remit $250.00 for renewal fee. + Return renewal applleation in GREEN envelope. + Ada late fee of $25.00, if necessary. + Enelose check with coupon in BLUE envelope. Registration No: 76366 Renewal Date; 09/25/97 1. Activity Stas: (Active (Retiring (see instructions) (Checkonlyons) Inactive *(see below) FE] Donot wish to renew 2, Other Name(s), if any, under which you were licensed: Corrections type or print) ther Name(s: 3. A)Mailing/Home Address: JONATHAN $ FRIEDES, M.D. Malling AdGreSS: City/Town: State Zip: Country: fee B) Business Address: i : 7 Phas’ Pion asa ee aa 2 FENWAY PLAZA ityTown State BOSTON, MA 02215 Bip EEC eee CEC Commer ese eceeSeeeee [Sse ae ence EeESS EEE Home), Home Phone: : J Business Phone: (617)421-1332 Business: (__)._ ae Date of Binh (M/DIY): _/ Sex (MIF): 4, A) Date of Binh ©)Sex: M 7 an a 3) Lie. ssue Date: 06/29/92 0) SSi eee pee | SS; ____ Ful) Name of Medical School: 5, A) Name of Medical School Yale University School of Medicine [7 a BB) Year Graduated: 88 © C) Degree; MD Year Graduated: ___Degree (MD/DO): 6. Specialty Code(s) (See Table 1) Codes) ours Per Week in Mass Code(s) Hours per Week in Mass paleeieanaea OBG 50 Obstetrics and Gynecology, he coorection IFS, Print Specialty 7. Current American Board of Medical Specialties Certification (See Table 2) Code: OG Code: Cote: SC 8, Drug License Numbers, if any: = A) Federal (DEA): Eee B) Massachusetts: ass: 9, A) Other states where you are now licensed to practice Abbr: CA Abbr: _ a BB) States where you previously were licensed 10 practice ‘Abbe: BE Abbe: +*1f requesting Innetive status, you agree not to practice medline, including writing prescriptions, in MassachusettsRegistration Number, 76 965 10.A. Curent health cae faites at which you have completed the eredetialng proces or he provision of patient cae. Supply the codes from Table 3 and place ebeck mgrk next o those hes are facilis where you have admiting prilcaes (AP). Facility Code: 7 2 1/¥(AP) Facility Code: 7 7/_ (AD) Facility Code: Facility Coes: 4 ©: ily Code: (AP) Frelliy Code 1999, pit narel): 18, Aditional health care facilities at whic you previously held privileges er with which you were associated in the past wo (2) yeas (See Table 3) PRINT NAME AND NUMBER: Last Name: FE DIE > (AP) AP) Focilty Code:____Pacilty Cade____ Facility Coue:__ Facility Cade:_____ Facility Code 1799, write Names): a Zc Bead 11. My medical malpractice insurance is covered by a) _V/ Insuranee Carrer b) Letter of Credit Name of insurer: Contofled Righ TFrowence Company of ernest, Tre. e status bt Tm not covered hy medical malpractice insurance because ‘Alternatively, indicate as follows: 1am registering with Ac ‘am (heck one) a)_____ Not involved in directindret patient care in Massachusetsb)__ Otherwise exempt Please explain exemption: 12. Ave you currently ina pos graduate ining rogram in Massa resident olin fellow? (chek one) aves wo 13. A, Wat is your principal work seting? (See Table 4) /£ QD 1. Cav of patents in Masschusets (se insireton bok. 1) Average weekly hours involved in 8) ouipationtcare “36 trstwk —) inpatient care A evvk 2) What isthe approximate percentage of your patient care hours in primary care? 2O_v PART A mucstions {4 through 22 refer to the past two (2)_ years only.. Cheek either YES or NO (NOT N/A) to each question, Provide details o YES answ for: Refer to the instru F additlonal mand definitions. INTHE PAST TWO (2) VEARS: 4, CLAIMS MADR: Has any medica! malpractice claim been made against you that has nat yet beon finely sete oF ‘adjudicated, whether or nota lawsuit was fled in reltion to the claim? 15. CLAIMS RESOLVED: Has any medical malproctice claim thot has been made against you been settled, adjudicate, or otherwise resolved, whether or not lawsuit was filed in relation tothe claim? 16. Las ony lees other than medical malpractice suit, which is reed to your competeney to practice medicine, or your professional conduct fn the practice of medicine, been fled upainst you or heen settled, adjudicated or otherwise resolved? 17, Have you been charged with any criminal offense oer than a minor traffic violation? 18. Have you boen formally charge! with or disciplined for any violation ofthe rues, by-laws or standards of practice of any ovecnmental nuthorty, healthcare facilis, group practice or professional society or association? 19, as your privilege to possess, dispense or nreseribe controlled substances been surrendered to or suspended, revoked, denied or restricted by any state or federal agency? 20. ave you withdrawn an application fo a medica iense ur been denial medical license for my ason!? 2. tas any professional tisilty insurance provider reset, limited, terminated, imposed a surcharge or co-payment, oF raced ay contin rested to profesional eompctency conduct on your voverage or have you voluntarily restricted, ited lerminaed your insurance coverage in response to an inauiry by a profesional liability insurance provider? 222. Mave you completed your CME. requirements preceding your renewal dae (se istration bookley? [Waiver reauested (waiver foam dv 30 dey pra ode ofcense expiration). {[} ‘Teaning Progra exernpion See Instructions for CME Fequirements. Do not submit documentation of your CME with your renewal application. RENEWAL APPLICATION CONTINURD ON PAGE 3. ALL QUESTIONS ON PART 8 MUST BE ANSWERED. Signature (Qa Ae dae 2 127RETURN To: BOARD OF REGISTRATION I weprense MAY 72 {TEN wet STREET, THIRD FLOOR, BOSTON, ata son VERIFICATION OF LICENSURE {In spplylog for license to practice medicine in the Commonwealth of Maseachusats, the Board of Resatration in Medicine requires that tle Crm be completed by each state where hold or have over held eansure. ‘Tl is your authority to release any information ia you flea favorable cr otherwise, Please send ths form dlrectly tothe Board atthe above addess. Your early reeponse ie greatly ppreclated. ae Seer ene pae tke elie mene NAME OF PHYSICIAN: Los sthion S_Erivdes License NuMBER: 506% 47 ‘THE STATE BOARD FILLS OUT THE FOLLOWING INFORMATION 1s Licanea Current: ye No Ine, why net? ae this Lente been suspended or revoked yes____No Ie yo, why, Has Licanase evar bean on probation? ves_____No. It yee, why, Hine Licenuee evar been requesiad to appear before your Board?__YBS_NO eye, why, DEROGATORY INFORMATION, IF ANYT, Comm Signed: Date: Title: STATE SEAL STATE BOARD. NOTE TO APPLICANT: Most ‘before you mai this form. ates charge fe fer tle vice. We auggett you call the diferent etaten in which you are licensedJAN TO; BOARD OF REGISTRATION IN MEDICINE {BST STREET, THIRD FLOOR, BOSTON, Ma 0211 VERIFICATION OF LICENSURE Commonweaith of Maaachutetts, the Boned of Registration in Medicine requres thot your Gla, ‘spprecated, vanes or rrvacun onion, Frieder —— urcevamnoeoem I 760 (epS s/o?) ASNBSTATE BOARD FILA OUP THE FOLLOWING PORATION State of__Hawaii Full Name of Leensos:__Jonathan S. Friedes. Gredunie of, __ Yale University School of Medicine Leese Number,__MD=7163 wou Date__June_ 8, 1990 endomemant/Reirosty wth:__ National, Board fy Your Sate Boar's Wetan Beaminaton? Yu___Ne 1a ican Cv Ye 5 raven ara silt as thie Licata ben spend orvoke ves__ go yes yt seen rant _va8_(@) ee oe cs) tye ey, DRROGATORY INFORMATION, IF ANY?, Swe a on duet et BF Tie wa with. g IESE <. CINSUMIER ARE AIRS | = fe svaroseat —stavpnonnn.__1] Soot oe teva dai dl Eames “ah gt NOTE TO APPLICANT: Mot state thie frm. cnacge fee fr tie service, We nuggent you call the diffrent states {a which you are HicensedCOMMONWEALTH OF MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE SUPPLEMENT TO APPLICATION FOR___LICENSE TORE GOURIETED By APPLICANT, PLEASETVPE ON PRA 7 NAME: —Toutows 9. Friedl. Day tw phone # | ‘MALIN ADDAESE: Benn Re sam Prove, Garr Harte! a Oey 00 Mes Taree oth Appin 29 Pere See BE Ea a0 ‘YOU ARE REGUIRED TO COMPLETE THE QUESTIONS BELOW. IMPORTANT NOTE: The Boars regulations, 249 CMA.802, define “éecptney exon aa refered tin the questions on this apailoaton. Pies consult ‘tis dotnton, which flows tle potion ofthe epption, wea 1. Haw any medical maiprectie clam been meds againt you nthe last an years (htc not await was fed nelatlon tothe cli)? (You muet complete Form 1B, aiached, or aac car) 2. Have you ever been dened the ight to participate oc env ln any eyatom whereby ates pty pays all or partol a patents iit? 3. Have you evar applied for Vounwute ort sit fran examination or taken an examination under a dirent name? #90, previous name: 4. Have you evr bean dacied tia priloge of taking or risking aa examination or been aeause of cheating and/or Improper conduct duag an examination or othorwlse been subject to any cleciptinay acon (6 deiton) ‘stan aoedemie Inston ence your mateslaton a colege? '8, Hove you over ale any ofthe fllowingexarinatione: the FLEX examietion, any tats Board examination, alld Par I ofthe "National Boards or fled t ain oertiiction trom the Nalonal Boar of Mectoa Examiners? {Have you eer ald forelgn eng or contcation examination? 7. Have you ever been denied a medical Hoense, whether ul mia or temporary fo any cessor? ‘8, Have you ovr has staf privages, employment or appoitmentin a hospital or other haath care Inthuton dened, euspaeded or revoked, or resigned from & media! eat abou of eecipinay acton (ee definition)? ‘8. ve any forma celpnary charges ponding o has any deipinary aedon (#88 defnton) been taken againet you lathe {uation yar by any governmental authonty, by any heap or hath cae fecity, or by any proteins cal essoteton (erations, national, eat fool)? 10, Have you over lunar eurendered a oones to penetce mein or any heating at? 11, Have you ver withdrawn an appiaton for medloal oartue, hosp prvlegen o appelntment or any reason? 12, Have you eva for any reaean, let Arerloan Speclaly Board Carifoation? 13, Have you been dene require recerticaton by one or more apeciay basa? # yo, whieh one)? 14, Rave you at any tne, baen a defendant ia any arinal proseediog other than minor Calis oees? 16, Has you privlege te pottsae, laponte ox prose controlled eubstancee aver been cutpendded,rvoksd, denied, rested or eurondred, or have you been oaled before or waned by tis atte or eny ctor utucotion loud a tedeal agoney et any time? 16, Have you ever had any amotenaldeturbanco or onal nese wish has Impaled your ably to practice medleine ‘orto funaion asa student of medicine? 17, Have you ever had an orzacio nese which has impaked your ability to practice medi oro function 26a etudent of medicine? 18, Ave younow, orhave you Been in the past, dependent upon eoohal or drugs? 18 Ha pe a ow ash ony barat eount? Hyena ons \forara ra 20, Have you var boon enotied in a oskdoncy taining program) tat you dd aot complete? “IMPORTANT: BEE FOLLOWING PAGES FOR FURTHER INFORMATION REQUIRED FOR "YES" ANSWERS.* [NOTE ON QUESTIONS 16-18: The harm that befalspystlane and patents lke whea Impalment goes undetected and unireetod ‘by tho medi! profession is devastating. The Goard wants Impaled physicians veated inthe eal tages of Ipaemant ‘before troparaie hav to the physician or patient occurs. \F RESPONSES TO QUESTIONS CHANGE DURING THE TME THE APPLICATION IS PENDING, THE APPLICANT MUST MAKE THE BOARD AWARE OF THE NEW INFORMATION. ‘cet tet wl ul my obiaton to report abuse or neglect of chléren punuant fo M.G.L e198 bo, 1A. |e rd te Boar regulation, 243 CMR 1.00 through 3.00, To te best of my krewladge Imeet the quacatins for ul Hoensure In Messachussts. "hceby cert unde the penly of perjury hat al information en this application, front, back, end al attachments fe wus, Gt Foie we iff SIGNATUR:: ae Commonwealth of Massachusetts Board of Registration in Medicine a S00 Harrison Avenve, Sule #G-4, Boston, MA 02118 (617) 6549810 hitpufwmv.nassmecbosrdong "gf Physician Registration Renewal Application = Before proceeding, please read the instruction booklet. Copy this form gnd all attachments for your own records; you was need copies for credentialing and other purposes. This completed renewal form with attachments must be returned inthe <2 -ezeen envelope gt least 4 weeks before your renewal date, mit $400.00 for renewal fee (non-refundable). Return renewal application in GREEN envelope, 2» Add late fee of $25.00, if necessary. Enclose check with coupon in BLUE envelope, __f Please review carefully the following information for accuracy and completeness. Make any corrections or alterations as required. Al] questions must be answered or your renewal will be delayed. 1, Current Stans: Active Registration No.76366 Renewal Date:09/25/2003 you want to change your current stats, please check one ofthe following boxes to indicate your new status: (Check only one) Cl active ——C) Retiring. (see instructions) Liinactive (see instretions) ——-] Do not wish to renew 2. Other Name(s) ifany, under which you were licensed: Laberirmctatia are A) Mailing/Business Address: Tl Other Name(s) L] Name Change (enter name below) 3. JONATHAN'S FRIEDES I B) Home Address fi tt AUC : aoe yeeeeed 8: Ag oe | : : fos as CityrTown: aie Home Phone: ee Coie Home Telephone! —(___). Business Phone: (617)344290% 4121-14) PLEASE NOTE: Only gag addres can bea PO. box. The railing address eannot be a P.O. Box. 4. a) Date of Birth: 1p) Sex: M 7. Current American Board of Medical Specialties Certification (See Table 2) Code: 06 Code: assy ; ae 8.Dnig License Number, °° 5: NAR BENGAL SSteoT oc Medicine Federal (DEA): ') Massachusetts: 1) Year Graduatedjggg ©) Degree: gp. 6, Specialty Code(s) (See ‘Table 1) tea and Gynecology 9, 5) Other states where yoy are now licensed to practice (Abbr) b) States where you were previously ieeyyea (abbr 10. Listall current healthcare facilities at which you are affiliated or have completed the credentialing process for the provision of patient care, (Supply the codes from Table 3 and place a check mark next to those health cate facilities where you bave admiting privileges (AP). Next to each facility, write the approximate pereentage of patient care hours that you provide in each feclity), __ No affibiations. Facility Code: 7 Ly Lan YO. % Facility Code:, Facility Code: § 9 2/_ (AP) Facility Code: 11999, piotnane( Wine Eng spect _/_(AP)___% Facility Code:___/_(AP)_% T= (AP) % Facility Code: (AP) %PRINT YOUR LAST NAME: _ LICENSE NUMBER: 224346 UL. Myamsial osbeietasine i sperety (sume Gi E} laeretate S=tonly Sheed GPR Insurer's name. (Requited):_C.& -e Policy dates: From: } /1 / Db To: !2/ 21/03 Alternatively, indicate s follows 1 an rgistering with Active status but I am not covered by medical malpractice insurance bectute 1am: Check One: [] Not involved in direcvindirect patient cre in Meseachusets C] A government employee CD oterwise exempt Please explain ckemption, 12. What is your principal work setting? (See Table 4) 2 © Ifyou are affiliated with a healthcare facility or credentialed for te provision of patient care you mist complete question #10 on page 1 and list your afiations, 13, Care of patients in Massachusets (see instruction booklet), 1) Average weekly hours involvedjin: A) inpatient care 244 brsiwk B) outpatient care 3 G bre/wk 2) What is the approximate percentage of your patient care hours in primary care?_Z.© % \4. CLALMS MADE (Sew or Pending): Has any medical malpractice claim been made against you that has not yetbeen finally setled or adjudicated, whether or nota lawsuit was fled in relation to the claim? 15, CLAIMS (Resolved): Hes any medical mslpractce claim that has been made against you been settled, ‘adjudicated, or otherwise resolved, whether or not x lawsuit was fled in relation tothe claisn? 16, Has eny lawauit, other thn a medical malpractice suit, which is related to your competency to practice medicine, 6 Your professional conduct inthe practice of medicine, been fled against you or been settled, adjudicated or ‘otherwise resolved? 17, Have you been charged with any criminal offense?” 18, Have you been charged with or discipied for any violation of laws, rules, by-laws or standards of practice of ‘ny governmental thority healthcare facility, group practice or professional society or association? 19. Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by, ot surrendered to any sate or federal agency? 20, Have you withdrawn an application for & medical license or been denied a medica license for any reason? 21 {as any profes ality inane provider etd ited trated, posed a usbarge co-payment, or placed any conuition related to professional competency or conduct on your coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in response to en inquiry by a Professional Liability insurance provider? wa 22, CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date? [Ef Yes Ci CME Waiver. CME waiver form must be submitted atleast 30 days prior to cease expiration date, SMEEXEMPTION: Checkons: [) inactive status ) Residency/Fellowship training (See instructions). See Instructions for CME watver or eXeruptions. Do not submit documentation of your CMs with appileation. * Pursuant to G.L. ¢. 112, Sec 1A, [understand my obligations to report abuse or neglect of children under G.L. c. 119, Sec, SLA and the punishment for failure to cofply. * Pursuant to GL. , 112, Sec. 2, will not charge to or collect from a Medicare beneficiary more than the Medicare fe schedule amount, ‘+ Pursuant G.L. c. 62C, 49A, I certify that Lhave complied with all laws of the Commonwealth related tothe filing of Massachusetts state tax tetums end payment ofall Meseachtetts sist taxes; reporting of employees and contractors under GL. ©. 628; and withholding and retiting child support pursuant to G.L-c. 119A. (See instroerions), Lod CN T hereby certify under the penaitles of petjury that all information on this Renewal Application, Part B and Form R is true.Massachusetts Physician Renewal Application Physician Name: Jonathan § Friedes, M.D. ‘required to notify the Board of Regist Business addresses CANNOT tf Post Office Box, License No.: 76366 PARTA 41) Current Status: Active Renewal Due Date: 0828/2007 Birth Date: {you want to change your curent status, please check one ofthe following boxes to indicate your new status ‘Check only one: (See Renewal Insructions, page 3.) D Active OF Retiring Di inactive 1 Do not wish torenew 2) Addresses & Contact Information irm your addresses and make changes, if necessary, You are Please make corrections (print) y" 30 days of any change of address. Home and 2a) MAILING ADpREss SEP 10 TOMALES OM peas etRestaion [tng ai: Mew) Vangund Padi! ve Boston, MA 02215 nMedicine ciyTown: " este = State: me Zip:__ OD ‘Country: Sea ce he hn abi ae 20) HOME ADDRESS — Ciyrtom: site zn Coun: ci Home Tekephores(__) 1 hc henge es Home tres carob a Pot Ofc Box 2) BUSINESS ADDRESS areas Harvard Vangaré Mesa a 133 Brodie ave Cig/Tom: Sie: Boson, MAOD215 cae Phone: (617)421-1191 Business Telephone: (__). ae 1 cht he ene nabs ‘Busines adress cannot bea Post ffs Baz ea Corceet your Email and Fax Number below: sil Address 4)Fax Number, (IDR) 5 Specialties (Se Ranval tuctons page) baa? | Lis Additonal Specanion Obstetrics and Gynecology o Seeeies a 6) Current American Board of Medical 5} (See enclosed instructions and Renewal Insructions page 4.) pecialtis (ABMS) or American Osteopathle Association (AOA) Information. List Certifying Board(s) below: ‘Update General Certificates and Subspecialty Certificates below. Please add additional Certifications as required. Board Name ABMS or AOAl Certificate/Subspecialty a Obstetrics & Gynecology ‘ABMS _ | Obstetrics and Gynecology ololalolf Page 1 of 9: Massachusetts Physician Renewal Application Physician Name: Jonathan § Friedes, M.D. License No: 76366 Please make cores 8 recesa7) 8) Other states where you are pow licensed to practice | feat cee eee ee 9) States where you were previously licensed mt (See Renewal Instructions, page 4.) 7) Drug License Numbers Corrections: 8) Massachusetts: ') Federal (DEA) ©) Federal (DEA) XS 10) List all work sites in Massachusetts, including health care facilities (where you are credentialed), private offices, clinics, nursing homes, etc. For the names of the health care facilities, refer to Reference Table 4 on page 18 of the Renewal Instruction booklet, Include any affiliations with Internet-based prescribing services jes. Please provide all information on all work sites, attaching a separate sheet, if necessary. Tacation = (See above and deseription on page 4,) (City or Town) State | Delete? Brigham & Women’s Hospital oO Faulkner Hospital a ‘New England Baptist Ho L “| | Harvard Varn Medial A rseciaty, Boston ma Harve Vanguard Cedica! _ thyvociets Semmens Ie <7 or comp: [Elst the names of all work sites in Massachusetts TH) Gare of patients in Massachusetts (Sag Renewal instructions, page 4) ‘Average weekly hours involved in: a) inpatient care 24 brs/wk Change to: —____brs/wk ) outpatient care 40 hrs/wk Change to: hrs/wk, ee Fo faccan heart a pasranianeies Policy dates: From L/L (0% ToL 1/02 ciate lice ne (Enclose a copy of the certificate of insurance or the face sheet) ‘Change to: ‘Type of Policy: 1D Letter of Credit subject to Board approval (Attach a copy.) 0 1am registering with Active status but { am not required to have medical liability insurance because I am: Checkone: C1 Notinvolved with director indirect patient cae in Massachusetts [1A Goverment Employee under Federal Tort Claims Act (FTCA) C1 Otherwise exempt (Please explain). 13) Do you perform any surgery in your Massachusetts office? (See Renewal Instructions, page 5S.) Yes» No Yes, please complete Form PCA-O “Office Based Surgery” Form on page 8, Page 2 of 9Massachusetts Physician Renewal Application Physician Name: Jonathan § Friedes, M.D. License Nos 76366 In questions 14-21, the phrase "time period” refers to the following — all time from the day you signed your last license Renewal Application to the day you sign this Renewal Application. (See Renewal Instructions, page) ‘You must check either YES or NO to each question, Provide details on Form R if you answer “YES” to any questions. Refer‘o ‘Renewal Instructions for additional information end definitions YES NO 14) CLAIMS MADE, ) 2) NEW: Have you received notification ofa claim, whether or not a lawsuit was filed on thet claim, or thas any medical malpractice claim been made against you during this time period? (see above). b) PENDING: Are there any unresolved malpractice claims against you today, ie., any claims that have not been finally settled or finally adjudicated? 15) CLAIMS CLOSED ‘Has any medical malpractice claim against you (whether or nota lawsuit was filed on that claim) been resolved, settled, or adjudicated during ths time period” 16) OTHER CIVIL LAWSUITS ‘Question 16 refers to claims or actions related to your competency to practice medicine or 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 time period? ») Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice ) Have any criminal offenses/charges against you been resolved during ths time period? ©) Are there any criminal charges pending against you today? t 4) Are any Applications for Issuance of Process pending against you? 18) INVESTIGATIONS AND DISCIPLINARY ACTIONS 1) Have you withdrav an application to any governmental authority, health care facility, group practice, ‘employer or professional association? 'b) Have you ever taken a leave of absence from any health care facility, group practice or employer? «) Have you been the subject ofan investigation by any governmental authority, health care facility, group practice, employer or professional association? <4) Have you been the subject ofa disciplinary action taken by any governmental authority, health care facility, group practice, employer or professional association’? 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by, or surrendered to any state or federal agency? 720) Have you withdrawn an application for a medical license, allowed a license application to become obsolete ‘or have you been denied a medical license for any reason? 721) Has any medical liability incurance carrier restricted, limited, terminated, imposed a surcharge or ‘co-payment, or placed any condition relate to professional competency or conduct on your coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by ‘a medica liability insurance carrier? 22) CME CERTIFICAT FF 2) Have you completed your CME requirements preceding your renewal date? GAVes [1] No ) If no, are you requesting a CME waiver? Yes [No ACME waiver request form mast be submitted atleast 30 days prior fo your license expiration date, 6) Ifyou are exempt from CME requirements, check reason for exemption. (See Renewal Instructions, page 8) CME EXEMPTION: (check one) (1 Inactive Staus C2 Resideneyellowship taining Page 3 of 9Massachusetts Physician Renewal Application 5 Physician Name: Jonathan S Friedes, M.D. License No 76366 PART C ‘Check One: ® PR 4 DJ have reviewed my Physician Profile at hip iprfilesmassmedboard.ore and confirm that he information is acura (Please note that if you changed or corrected your business address, business phone number, practice specialty. board certification and/or hospital affiliations on your renewal application, your Physician Profile will also be updated) have reviewed my Physician Profile and attached a copy of the Profile with corrections. C1 My statu is inaetive and I do not have a Physician Profile. (See Renewal Instructions, page 11.) ‘CERTIFICATIONS 1) Loertfy that { have complied with my obligations to report abuse or neglect of children pursuant to G.L. ¢. 119, sec. SLA, and 1 ‘understand the punishment for failure to comply, 2) I certify that I have complied with my obligations to report abuse or neglect of disabled persons pursuant to GL. e. 19C, see. 10, and TTunderstand the punishment for failure to comply. +3) I certify that I have complied with my obligations to report abuse, neglect or financial exploitation of elderly persons pursuant 10 G.L.€.19A, see. 15, and I understand the punishment for failare to comply. 4) I certify that | have complied with my obligations to report the treatment of wounds, burns and other injuries pursuant to G.L. ¢. 112, see. IZA. 5) l cectify that 1 have complied with my obligations to report the treatment of victims of rape or sexuel assault pursuant to G.L. ¢. 112, see. 12 172. 6) I certify that Ihave complied with my obligations to report a physician to the Board of Medicine, pursuant to G.L. c. 112, see. SF, when T have a reasonable basis to believe that person violated any provisions of GL. ¢. 112, sec. or any Board regulation. 17) certify that I have complied with ray obligations related to charging and collecting fees from Medicare beneficiaries in accordance with the Medicare fee schedule, and I understand my obligations under GL. c. 112, sec. 2. 8) I certify that have complied with my obligations to file Massachusetts tax returns and to pay Massachusetts taxes, and I understand ‘hat, pursuant to G.L. ¢, 62C, see. 49A, my license shall not be issued or renewed unless I make these certifications under penalties of perjury. 9) L certify that [have complied with my obligations related tothe reporting of employees and contractors pursuant to G.L. 62E. 10) I certify thet Ihave complied with my obligations related tothe withholding and remitting of child support pursuant to G.L. ¢,1194. 11) certify that 1 have complied with my obligations to file an Incident Report with the Board when certain adverse events occur in my private office, pursuant to GL ©. 112 sec. $ and the Patient Care Assessment Regulations, 243 C.M.R. 3.00 ¢¢seq. I understand that the Patient Care Assessment (PCA) programs atthe health care facilities where I practice report certain Major Incidents to the Board 12) | certify thet I have complied with my obligations to disclose my ownership interest in eny partnership, corporation, firm or other Jegal entity to which I have referred a patient for physical therapy services pursuant to G.L.c, 112, sec. 124A. Under penalties of perjury, I declare that I have examined this renewal application and all its accompanying instructions, forms and statements, and to the best of my knowledge and belief, the information contained herein is true, correct, and complete. As an applicant for renewal of a license to practice medicine, I understand that a criminal record check may be conducted for conviction and pending criminal case information from the Criminal History Systems Board only and that it will not necessarily disqualify me from licensure, Signature: mea pate: 2 14 102 MAKE A COPY OF YOUR APPLICATION AND ALL. ATTACHMENTS BEFORE MAILING. YOU MUST RETAIN A COPY OF YOUR APPLICATION FOR YOUR RECORDS, FOR CREDENTIALING AND FOR OTHER PURPOSES. Page 5 of 9Massachusetts Physician Renewal Application : Physician Name: Jonathan $ Friedes, MD. License No: _ 76366 NATIONAL PROVIDER IDENTISIER (NPD x “The primary purpose ofthe NPI isto wniguely identify healthcare providers as “healthcare providers” in HIPAA standard transactions “Toe NET wilveplac aller identifiers assitned to health care provides, suchas those assigned by helt plans, government programs and health care purchasers for purposes of conducting these busines: s$ transactions. EE Cader the Ral HIPAA NPI Rete, al individual and organization covered providers will be vequired to abtain an NPI by May 23,2007. 1m order for your license to be renewed you must take one ofthe following actions: i: Qption 1: Supply the Board of Registration in Medicine with your valid NPI. You can apply for an NPI directly by using the NPPES web site at woe NPPES cms bbs £0¥. ‘Option 2: Certify you have personally applied for your NPI and you have not received it yet Once you have received your NPI Number, you must notify the Board, Please compte the NPI form atthe Board's web site at www. massmedboard. ors. ption 3: Certify another authorized institution as applied for an NPI on your behalf and you have nt received it yet (supply iAsunuton’s name), Once you bave eeccived your NPI Nuaber, you must notify the Board by completing the NPI form atthe ‘Boarels website (see Option 2) ‘Option 4: Atthorize the Board of Registration in Medicine to aply for an NPI on your behalf 5; your lense stats is INACTIVE, you may elect not to obtain an NPI number. check she appropriate box below, supply appropriate information, and sign the bottom of the page: Myonenxris (S| [o) CALC 15 thave personaly applied for en NPI. (You must previd your NPI number to the Board when recived) 1D the applied for an NP sig hed party (enter nae): (Gollow istretons for Option 3) 1D By eheckng this option and signing the bottom ofthis page, hereby authorize the Boar to apply fran NPI on my beta. 1 Asan inactive physician, I do not wish to obtain an NPL. Please provide the HIPAA taxonomy (specialty) codes (refer to Renewal Instructions, page 21 for more information). In addition 10 providing the taxonomy code, plense indicate your specialty in the space provided (Texonomy Description). The primary provider taxonomy code is required if you authorize BORIM to apply for an NPI on your behalf. Taxonomy {Soesilty) Code ‘Taxonomy Descrston Print Primary Provider Twooomy: =» IAIRTUTALellalaliobs] § _Ovetu, al sf. Provider Taxonomy: Ooooooodo ¥ Provider Taxonomy: ia] OO ‘NPLREQUIRED INFORMATION In an ongoing effort to improve the quality of the information we collet, please review the following information and make corrections ‘as necessary. Please note: This information is required if you authorize BORIM to apply for an NPI on your behalf, Social Security Number: State of Birth (iF US) wy Country of Bith (if outside the US) Gender: fale O Female Penalties for Falsify tional Pri t 18 USC, 1001 authorizes etal peatiosepnt an individual wh in ny mater within the jurisdiction of ary deparenent or agency of Hera 'sexe beowmgly and willy falls, conceals or covers up by any tick, scheme or device a materia et, or makes any fle, een at uments or representations, or makes ary false writing or document knowing he same to contain any fas, seth oat et satement oven Individual efeners are sbjet to ines of up o $250,000 and inpriscament for upto five years. Ans et ca craniations are abject to Fes of upto $300,000, 18 U.S.C. 3571() alo authorizes fine of up to twice the gross gain Served bythe otender ite grater than the amount specfcally authorized bythe sentencing statute ion for NPLDissemination Checkone box: authorize (Ido pot authorize the Board of Registration in Medi Sthorlzedespitl, health plan, ox health organiza Please sign and date to confirm that all of the information on this form is true and accurate, ‘Signature: 3 pate: 21 _¥ 02 Page 7 of 8 / to provide my NPI number to any“Mass.Gov - Massachusetts Board of Registration in Medicine Page | of 3 Mass.Zjov “one sev gens ete ale 2° — Back | Home | How to Read Profile : Massachusetts Board of Registration in Medicine Physician Profile B Jonathan S. Friedes, M.D. ] Physician Information (The information in sections | - VI has been provided by the physician.) License Status: Active License Issue Date: 6/29/1992 Accepting New Patients: Yes Accepts Medicaid: Yes Primary Work Setting: Partnership or Group Practice Business Address: Harvard Vanguard Med asso. 133 Brookline Ave Boston, MA 02215 Spanrsh Phone: (617) 421-1191 oasgray Translation Services Available: None Reported Madan Crak Insurance Plans Accepted: Blue Cross Blue Shield Lotaley, Harvard Pilgrim Health Care French Neighborhood Health Plan Numerous Plans Accepted Tuts Health Plan Hospital Affiliations: Brigham & Women's Hospital (Admitting) Faulkner Hospital (Admitting) "1 Education & Training Medical School; Yale University Schoo! of Medicine Graduation Date: 1988 Post Graduate Training: Univ Of Calf San Francisco - Intern/Resident (6/21/1988 5730/1992), — Mh, ‘Specialty Area.of Specialty: Obstetrics and Gynecolegy S—_] hitp://profiles.massmedboard.org/MA -Physician-Profile-View-Doctor.asp?ID=12454 9/4/2007Mass.Gov - Massachusetts Board of Registration in Medicine Page 20f3 N, Board Certifications American Board of Medical Specialties (ABMS) Board Name ‘General Certification Subspecialty Obstetrics & Gynecology _Obstetries and Gynecology eee Vv. Honors and Awards Harvard Pilgrim Peer Recognition Award 1996 -— Vi. Professional Publications ‘This physician has reported no publications. ees vil. Malpractice Information ‘Some studies have shown that there is no significant correlation between malpractice history and a doctor's competence. At the same time, the Board believes that consumers should have access to malpractice information. In these profiles, the Board has given you information about both the malpractice history of the physician's specialty and the physician's history of payments. The Board has placed payment amounts into three Statistical categories: below average, average, and above average. To make the best ‘health care decisions, you should View this information in perspective. You could miss an ‘opportunity for high quality care by selecting a doctor based solely on malpractice history When considering malpractice data, please keep in mind: + Malpractice histories tend to vary by specialty. Some specialties are more likely than others to be the subject of itigation. This report compares doctors only to the members of their specialty, not to all doctors, in order to make individual doctors history more meaningful + This report reflects data for the last 10 years of a doctor's practice. For doctors practicing less than 10 years, the data covers their total years of practice. You ‘should take into account how long the doctor has been in practice when considering maipractice averages. ‘+ The incident causing the malpractice claim may have happened years before a Payment is finaly made. Sometimes, it takes a long time for a malpractice lawsuit to move through the legal system. * Some doctors work primarily with high risk patients. These doctors may have ‘malpractice histories that are higher than average because they specialize in cases © Batients who are at very high risk for problems, ‘+ Settlement of a claim may oceur for & variety of reasons which do not necessarily reflect negatively on the professional competence or conduct of the physician. A http://profiles. massmedboard.org/MA -Physician-Profile-View-Doctor.asp1D=12454 9/4/2007‘Mass.Gov - Massachusetts Board of Registration in Medicine Page 3 0f 3 Payment in settlement of a medical malpractice action or claim should not be construed as creating a presumption that medical malpractice has occurred. ‘You may wish to discuss information provided in this report, and malpractice generally, with your doctor. The Board can refer you to other articles on this subject. : Or. Friedes has not made a payment on a malpractice claim in Massachusetts in the past ten years. SEE vit Disciplinary and/or Criminal Actions A. Criminal Convictions, Pleas and Admissions: ‘The information in this section may not be comprehensive. The courts are now required by law to supply this information to the Board, Dr. Friedes has had no criminal convictions in the past ten years. B. Hospital Discipline: ‘This section contains several categories of disciplinary actions taken by Massachusetts hospitals during the past ten years which are specifically required by law to be released in the physician's profile, Dr. Friedes has no record of hospital discipline in the past ten years. C. Board Discipline: ‘This section includes final disciplinary actions taken by the Massachusetts Board of Registration in Medicine during the past ten years, Dr. Friedes has not been disciplined by the Board in the past ten years. —_—. ‘Additional information about a physician, including closed complaints, may be available by Calling the ‘Massachusetts Board of Registration in Medicine Phone 617-654-9830 Toll Free Number (Massachusetts only) 1-800-377-0550 Return to Physician Profile Search Direct questions and comments about these results to Massachusetts Board of Registration in Medicine ‘580 Hartison Avenue, Boston MA 02118 Phone 617-654-8800 For direct response please use Email Please read the Board of Registration in Medicine Disclaimer 152006 Commonweati of Meseachueets vasy poicy ste map |hutp://profiles. massmedboard.org/MA -Physician-Profile-View-Doctor.asp?1D=12454 9/4/2007Massachusetts Physician Renewal Application Physictan Name: JONATHAN S FRIEDES License No: 76366 Renewal Due Date: 08/28/2005 Birth Date: If yoo want to change your eurent status, please check ane ofthe following boxes to indicate your new status (Check only one). (See Renewal Instructions, page 3.) 1 Active D1 Retiring O toactive D1 Do not wish to renew 7) Addresses & Contact Information. Please confirm your addresses and make changes, if ecessary. You are required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and ‘Business addresses CANNOT be a Post Office Box. ‘Please make corrections (print) 2a) MAILING ADDRESS Mailing Address: City/Town: State: Zi: Country: Oh Check here so chong is adess ) | CityrTown: State: fe County Phone: a ome Telephone (_) : oe etheewtantiatigan Bocce | Home adress carmel bee Pst Ofee Box 2e) BUSINESS ADDRESS ‘Business. . HARVARD VANGUARD MED.ASSO. os 133 Brookline Ave ciyrTowm: ‘Sate: BOSTON, MA 02215 Zip country: Telephone Phone: (617)}421-1191 a Ce 1 Chek reo change iis ‘Business adores canner be a Post Office Bax 3) Eemall Address: _ Fexnamber: (62) _Prl= S82 1 Spodalties (See Renewal nsractons page 4) Detwe? | _ Additional specials: Obstetrics and Gynecology o a a © Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information. (See enclosed instructions and Renewal Instructions, page 4) Tat Corin Board ble: pare Gener Coit ad Subp Coats +] han Ws a sional Crean evel Board Name ABMS or AOA] Certificate/Subspecial Correcy? Delete? Obstetrics & Gynecology ABMS Obstetrics and Gynecology o o o piaao o oO Page 1 of 5 zs wLoe0Massachusetts Physician Renewal Application -Physiclan Name: JONATHAN § FRIEDES License No.: 76366 { (See Renewal instructions, page 4) Please make corrections as necessary 7) Drug License Numbers, if @ny: 8a) Other states where you are now licensed to practice (Abbr) 4) Massachusetts EGA gee eee eree ee eeceaee cece b) Federal (DEA): ~ £8) States where you were previously licensed (Abbr) ©) Federal (DEA) XS: See eee este tee 9) What is your principal work setting? (See Renewal Insructons, page 4.) Principal Work Seting: Partnership or Group Practice Change to: Please enter the appraximate number of work hours at your principal work setting: _4O. 10) List all current healthcare facilities where you are affiliated or have completed the credentialing process for the provision of patient eare. (Supply the name ofthe health care facility from Reference Table 5 on Page 16 ofthe Instruction bookie). Next 10 each facility write your staff category at that facility (Admitting, Active, Courtesy, ‘Associate or Consulting) and the approximote number of hours of patient eare that you provide at that facility. Include any affiations with on-line prescribing services or companies. Please provide al Information for additional facies ona separate sheet, i uecessary. No Affiiations [] Please enter the gzpraximate number of work hours for each Health Care Facility below: ‘eatth Care Facility (See Renewal Instruction, page #) oe a ‘Brigham & Women's Hospital O_ [Admitting 2y Other Fraime Hospital | adeoti o Mew Begin) Gypise Paphl [oe ent sq) O | Aare ° oO +- a a oO 15) Care of patients in Massachusetis (See Renewal Instructions, page 4) ‘Average weekly hours involved in: a) inpatient care _24_ hrswk Change to: Ihsfvk outpatient care 36 hrsiwk Change to: _4_ hrs/wk 12) Medical Liability Insurance Information (See Renewal Instructions, page 5.) ‘My spéGical lability insurance is provided through: (check one) ‘Insurance Carrier (complete below) ‘Current Insurance Carrier: CRICO_ ‘Change to: Policy dates: From J J (05 To /2 13) 10% Gequired)—(cwitinaous cavtang sive. (992) 1D Letter of Credit subject to Board approval (attach a copy) Yam registering with Active status but I am not required o have medical liability insurance because 1am: CNet invotved with direct or indirect patient core in Massachusetts [Government Employee Federal Tort Claims Act (FTCA) 1 Otherwise exempr (Please explain) Page 2 of 5 2S $0/L0/60 wieMassachusetts Physician Renewal Application Physician Name: JONATHAN S FRIEDES, License No. 76366 15) Do you perform any surgery in your office? (See Renewal Instructions, page 5.) Fes, please complete Form PCA-O "Office Based Surgery” In questions 14-21, the phrase "time period” refers to the following: ‘You must cheek either YES of NO to each question. Provide details on Fon R if you answer “YES” to any quest Renewal Instructions for additions! information and definitions. ALL. questions in this section must be answered. time from the day you signed your last license revewaVapplication, to the day you sign this renewal application, inclusive, (See Renewal Instructions, page 5) y L089 28 50, 14) CLAIMS MADE. ‘8) New: Has any medical malpractice claim been made against you during not a lawsuit was filed on that claim? 'b) Pending: Are there any unresolved malpractice ela finally setted or finally adjudicated? ime period, whether or | ‘against you today, any claims that have not been sis 35) CLAIMS PAID Has any medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during this time period? 16) OTHER CIVIL LAWSUITS: ‘Question 16 refers to claims or actions related to your competency to practice medicine or your [professional conduct in the practice of medicine. 4a) New: Have there been any lawsuits, other than medical malpractice eleims, been fled against you during thistime period? +) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during this time period”? 17) CRIMINAL CHARGES: '8) Have you been charged with any criminal offense during this time period? ') Are there any criminal charges pending against you today? | ) Have any criminal offenses/charges against you been resolved during this time period? Ta) Have you been charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of any governmental authority, health care facility, group practice or professional society or association? 719) Hes your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, ‘denied, restricted by, or surrendered to any state or federal agency? 30) Have you withdrawn an application fore medical license, allowed e license application to become obsolete or have you been denied a medical license for any reason? Fi) Has any medical lability incurance carrer restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition related to professional competency or conduct on your coverage, oF hve yoo velontarily restricted, limited or teminated your insurance coverage in response to an inguty by a medical Viability insurance caer? 22) CME CERTIFICATION: ae ‘2) Have you completed your CME requirements preceding your renewal date? ‘es No b) Ifno, are you requesting a CME waiver’? {11 Check to request CME Waiver. A CME waiver request form mis be submited at least 30 days prior fo your license expiration date. (See Renewal Instructions, page 8) c) If you are exempt from CME requirements, check reason for exemption. (See Renewal Instructions, page 8.) CME EXEMPTION: (check one) EJ. Inactive Status CD Residency/Fellowship trining Page 3 of 5Massachusetts Physician Renewal Application Physiclan Name: JONATHAN S FRIEDES License No 76366 PHYSICIAN PROFILE D_Yrave reviewed my Physician Profile t profiles messmedboard.rg and confirm tht the information is accurate. Ihave reviewed my Physician Profile and attached a copy of the Profile with corrections. : _Mystausis inactive and} donot have « Physician Profile. (See Renewal Instructions, page 10.) CERTIFICATIONS 1) 1 centfy that | have complied with my obligations to report abuse or neglect of children pursuamt to GAL. €. 119, see. S1A, and I understand the punishment for failure o comply. 2) lcerfy that 1 have complied with my obligations to report abuse or negleet of disabled persons pursuant to G.L. c. 19C, see, 10, and J understand the punishment for failure to comply. 3) I cetfy that I have complied with my obligations to report abuse, neglect or financial exploitation of elderly persons pursuant to G.L. ©.19A, se. 15, and I understand the punishment for failure to comply. 4) I certify that | have complied with my obligations to report the treatment of wounds, burns and other injuries pursuant to Gc. 112, sec. 124, '5) | centify that I have complied with my obligations to report the treatment of victims of rape or sexval assault pursuant 10 GLe. 112, sec. 124 12. ©) centfy that I have complied with my obligations to report a physician to the Board of Medicine, pursuant to G.L, . 112, see. SF, when I have a reasonable basis to believe that person violated any provisions of G.L. c. 112, sec, 5 or any Board regulation. 7) Lcentfy that I have complied my obligations related to charging and collecting fees from Medicare beneficiaries in accordance with the Medicare fee schedule, and I understand my obligations under G.L. ¢.12, see. 2. 8) I certify that I have complied with my obligations to file Massachusetts tax returns and to pay Massachusetts taxes, and I ‘understand that, pursuant t0 G.L. €. 62C, sec, 49A, my license shall not be issued or renewed unless I make these certifications under penalties of perjury. 9) 1 certify that I have complied with my obligations related to the reporting of employees and contractors pursuant to G.L. CORE, 10) I certify that I have complied with my obligations related to the withholding and remitting of child support pursuant to GL.c. 119A, 51) 1 cemtfy that} have complied with my obligations to file an Incident Report with the Board when certsin adverse events ‘occur in my private office, pursuant to G.L. c. 112 sec. 5 and 243 C.M.R. 3.00 et seq. and | understand thatthe Patient Care ‘Assessment (PCA) programs atthe health care facilites where I practice report certain Major Incidents to the Board. Under penatties of perjury, I declare that I have examined this renewal application and all its accompanying instructions, forms and statements, and to the best of my knowledge and belief, the information contained herein is true, correct, and complete. I authorize the Board of Registration in Medicine to access any and all criminal case information on me held by the Massachusetts Criminal History Systems Board. Sionature:_ KD Date: / 3h a MAKE A COPY OF 4OUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING, FOR YOUR RECORDS, FOR CREDENTIALING AND OTHER PURPOSES. Page 6 of 5 s0-20-60 zs aCommonwealth of Massachusetts & Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan $ Friedes, M.D. License No.: 76365 Current Status: Active License Expiration Date: 9/25/2009 1) Activity Status: Active 2) Address & Contact Information Mailing Address: Harvard Vanguard Medical Associztes 135 Brookline Avenue Boston Massachusetts - 02215, United States of America Home Address: Business Address: Harvard Vanguard Medical Associates 133 Brookline Avenue Boston Massachusetts - 02215 United States of America (617) 421-1791 3) Email Address: 4) Fax Number: (617) 421-5828 8) Specialties Obstetrics and Gynecology ® Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (aoa) formation, ABMS/AOA Board Name Certification ‘Subspecialty ABMS: Obstetrios & Gynecology Obstetrics and Gynecology Federal (DEA) Federal (DEA) XS. 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed California Hawaii 10) Work Sites offce, eINers sites In Massachusetts, including health cere faites (where you are credertised), private office, cinies, nursing homes, ete Worksite Location Brigham & Women's Hospital Paget of 5 ate: 87262009, “Time: 5:28 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan $ Friedes, M.D. License No.: 76366 Faulkner Hospital Harvard Vanguard Medical Associates Boston Harvard Vanguarc- Somerville 11) Care of patients in Massachusetts Average weekly hours involved in: a) inpatient care 24 hrsivk b) outpatient care 40 nrshvk 12) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEnd Date —_—Policy Type Controlled Risk insurance Company of Verrn 1/1/2008 1213172009 Claims made with tail coverage 18) Do you perform any surgery in your Massachusetts office? 414) Claims Made a) New: Have you received notification of a claim, whether or not a lawsuit was filed on that claim, or has ‘any medica! malpractice claim been made against you during this time period? b) Pending: Are there ary unresolved malpractice claims against you today, |, any claims that have not been resolved, settied or adjudicated during this time period? 16) Claims Closed Has any medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been resolved, seitied, or adjudicated during this ime period? 16) Other Civil Lawsuits ‘Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 2) New Have there been any claims, ctner than medical maipractice clams, ted agairst you dung ths time perio b) Resolved. Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during this period? 17) Criminal Charges 42) Have you been charged with any criminal offense during this peniod? b) Have any criminal offensesicherges against you been resolved during this time period? () Are there any criminal charges pending against you today? 4) Are any Application of Issuance of Process pending against you? 18) Other Issues 2) Have you withdrawn an application to any governmental authority, health care facili, group practice ‘employer or professional association? b) Have you ever taken a leave of absence from ary health care facility, croup practice or employer? 0) Have you been the subject of an investigation by any governmental authorty, health cate faclity, group practice, employer or professional association? 4) Have you been the subject of @ disciplinary action taken by any governmental authority, health care facilty, group practice, employer or professional association? 19) Have your privileges to possess, dispense ot prescribe controlled substances been suspended, revoked, denied, restricted by or surrendered to any state or federal agency? 20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete or have you been denied a medical license for any reason? 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge ‘or co-payment, or placed any condition related to professional competency or conduct on your coverage, of have you voluntarily restricted, limited or terminated your insurance coverage in Fesponse to an inquiry by a medical liability insurance carrier? Page 20t5, Date: 272672008 Time: 5:28 PMCommonwealth of Massachusetts Physician Name: Jonathan $ Friedes, M.D. License No.: 76365 22) Have you completed all CME requiements (100 hours of CME of which 10 hours must be I isk management, Requirement: 40 hours credit in Category 1nd 89 hours in Category 2)for this Yes renewal period? (If you are in an approved Residency/ Fellowship program, or if your are renewing your licenise for the first time, please answer Yes) 24) Bo you have a medical condition that interferes Im any way or ints your abilty to practice ine? 24) Have you used any chemical substance(s) which in any way interferes with your ability to practice medicine’ Page 3ot5, Date: 0726/2008 ‘Tne: 5:28 PHL‘Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physiclan Name: Jonathan S Friedes, MD License No.: 76966 Current Status: Active License Expiration Date: 9125/2009 4) Activity Status: Active 2) Address & Contact Information Mailing Address: Harvard Vanguard Medical Associates 133 Brookline Avenue Boston Massachusetts - 02215 United States of America Home Address: Business Address: Harvard Vanguard Medical Associates 1433 Brookline Avenue Boston Massachusetts - 02215 United States of America (617) 421-1191 3) Email Address: 4) Fax Number: (617) 421-5828 Jeciates 5) Spebles and Gynecology 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMSIAOA Board Name Certification ‘Subspecialty ABMS Obstetrics & Gynecology Obstetrics and Gynecology 7) Dnug License Numbers Mascarhueatts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed California Hawaii 410) Work Sites Worrall work sites in Massachusetts, including health care faci office, clinics, nursing homes, etc Worksite Location Brigham & Women’s Hospital les (where you are credentialed), private Paget of 5 ate: 0762008 Time: 5:28 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan $ Friedes, M.D. License No.: 76365 Faulkner Hospital Harvard Vanguard Medical Associates Boston Harvard Vanguerd- Somerville 11) Care of patients in Massachusetts Average weekly hours involved in: a) inpatient cate 24 hrsik ) outpatient care 40 hrsiwk 112) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEnd Date —_—Policy Type Controlled Risk insurance Company of Ver 4/4/2008 12/31/2009 Claims made with tail coverage 19) Do you perform any surgery in your Massachusetts office? 14) Claims Made a) New: Have you received notification of a claim, whether or not a lawsuit was filed on that claim, or has ‘any medical malpractice claim been made against you during this time period? b) Pending: Ate there ary unresoived malpractice claims against you today, Le., any claims that have not been resolved, settled or adjudicated during this time period? 15) Claims Closed Has any medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during ths time period? 16) Other Civil Lawsuits ‘Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 2) New Have there been any claims, otner than medical malpractice claims, fled against you during tis time period b) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during this perioc? 17) Criminal Charges 8) Have you been charged with any criminal offense during this period? ) Have any criminal offenses/charges against you been resolved during this time period? ©} Ate there any criminal charges pending against you today’? ‘Are ary Application of Issuance of Process pending against you? 16) Other issues nave you withdrawn an application to any governmental authority, health care facility, group practice emplyer or profesconat seeccaton? wy ite You ever en leave of ater om any heath carly, group pacts or erp? ©) Have you been the subject of an vestigation by any goverment anor hy, heath care lly group Ffasiveersloyero pltestonal assosaton? ay Plave yollocentne saject of Ge pinay schon taken by ary governmertaleuhotty, health care tacky group praie, employer or profesional aes90tton 18) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by of surrendered to any state or federal agency? 20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete or have you been denied a medical license for any reason? 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge oF co-payment, or placed any condition related to professional competency or conduct on your coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by a medical liability insurance carrier? Page 2 0f 5 Date: 26/2008 Tie: 5:28 PRECommonwealth of Massachusetts fs) Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan § Friedes, M.D. License No.: 76350 22) Have you completed all CME requirements (100 hours of CME of which 10 hours must be in risk management. Requirement: 40 hours credit in Category 1 and 80 hours in Category 2) for this Yes renewal period? (If you are in an approved Residency! Fellowship program, or f your are renewing your licerise for the first time, please answer Yes) 23) Do you have a medical condition that interferes in any way or mits your ability to practice ine? 24) Have you used ar y chemical substanco(s) which in any way interferes with your ability to practice medicin. 20 PM. Page dof 5 Date: 872672009Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan S Friedes M.D. License No.: 76366 Current Status: Active License Expiration Date: 9/25/2013 41) Activity Status: Active 2) Address & Contact Information Mailing Address: Harvard Vanguard Med Associates 133 Brookline Avenue Boston Massachusetts - 02215 United States of America Home Address: Business Address: Harvard Vanguard Med Associates 138 Brookline Avenue Boston Massachusetts - 02215 United States of America (617) 420-1791 3) Email Address: 4) Fax Number: (617) 421-5828 5) Specialties Obstetrios and Gynecology 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMS/AOA Board Name Certification ‘Subspecialty ABMS Obstetrics & Gynecology (Obstetrios and Gynecology 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed California Hawaii 10) Work Sites List ofall work sites in Massachusetts, including health care facilities (where you ate credentialed), private office, clinics, nursing homes, ete Worksite Location Brigham & Women’s Hospital Pago of 7 Date: 072013. ‘Time: 10:02 PMCommonwealth of Massachusetts ty) Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan $ Friedes, M.O. License No.: 76366 Faulkner Hospital Harvard Vanguard Medical Associates Boston Harvard Vanguaro- Somerville 11) Gare of patients in Massachusetts ‘Average weekly hours involved in: a) inpatient care 24 hrshwk b) outpatient care 40 hrsiwk 42) Medical Liability insurance Information Insurance Carrier Policy Start Date Policy End Date Policy Type RICO 0110172013 4272112013 Claims made with tail coverage 419) Do you perform any surgery in your Massachusetts office? 14) Claims Made 2) New Have you recewes nottioaton of acta. whet! ch not a lawsuit was fled on that claim, or has ‘any medical malpractice claim been made against you during this time period’? py Petaling: Are there ary unresolved malpractice claims against you tocay.Le., any claims that have not been resolved, settled or adjudicated during this time penoc? 16) Claims Closed Fleas inecisal malpractice claim against you (whether or not 2 lawsuit was filed on that im) been resolved, settled, oF adjudicated dunng this time period? 16) other civil Laweults Other Cli Laws ims or ations related to your competency to practice medicine or your professional conduce m the praciee of medioine SMe velba) cle oe an moses maasioe cams Nes esnstyoudro me per 0) EERE Fave you resolved, sted or aucicated any awe, ether than medical malpractice Sisine, dung ths penas? 17) Criminal Charges S$) Have you been charged with any criminal offense during this period? B Hive bry criminal offersesicharges against you been resolved during ths time period? ¢¢) Are there any criminal charges pending against you today’? 8) Ate any Application of lesuance of Process pencing against you? 18) Other Issues Sieve you withdrawn an application to any governmental authority, health care facity, group practice employer oF professional association? by Have you ever taken a leave of absence from arry health cafe facility, group practice. of emplayer? 2) Fave You been the subject of an irvestigation by ery governmental authority, including the Free ets Beard cf Registration in Medicine or any other state medical board, health care facility, ‘group practice, employer oF professional association? 4) Have you been the subject of 2 cicipinary action taken by any goverrmental authorty, heath care Facil) group practice, employer or professional association? 19) Have your privileges to possess, dispense oy prescribe controlled substances been suspended, revoked, denied, restricted by of surrendered to any state or federal agency? 20) Have you withdrawn an application for @ medical license, alowed a license application to become obsolete or have you been denied a medical license for any reason? Page 2 0t7 Date: 772013 ‘Time: 10:02 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan S Friedes, M.D. License No.: 76368 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge of co-payment, or placed any condition related to professional competency or conduct on your coverage, of have you voluntarily restricted, limited or terminated your insurance coverage in fesponse to an inquiry by a medical liability'insurance carrier? 22) Have you completed all CPD requirements (100 hours of CPD of which 10 hours must be in risk management. Requirement: 40 hours eredit in Category 1 ‘and 60 hours in Category 2)for this Yes renewal period? (if you are in an approved Residency! Fellowship program, or if your are renewing your license for the first time, please answer Yes) Page ot? Date: 572013 Time: 10.02 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Name: Jonathan $ Friedes, M.D. License No.: 76366 23) Do you have a medical condition that interferes in any way or limits your ability to practice medicine? 24) Have you us ) practice medich any chemical substance(s) which in any way interferes with your ability to Page 4 of7 Date: 8172013, ‘Time: 10:02 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Jonathan $ Friedes, M.D. Physician Nam« Current Status: Active License Expiration Date: 9/25/2011 41) Activity Status: Active 2) Address & Contact Information Mailing Address: Harvard Vanguard Med Associates 133 Brookline Avenue Boston Massachusetts - 02215 United States of America Home Address: Business Address: Harvard Vanguard Med Associates 433 Brookline Avenue Boston Massachusetts - 02215 United States of America (617) 421-1191 3) Email Address: 4) Fax Number: (617) 421-5828 6) Specialties (Obstetrics and Gynecology 66) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMS/AOA Board Name Certincation ‘Subspeciatty ABMS: Obstetrics & Gynecology Obstetrics and Gynecology 7) Drug License Numbers Massachusotts Federal (DEA) Fedaral (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed California Hawaii 10) Work Sites Fee Siirork sites in Massachusetts, including health care facilties (where you are credentialed), private office, cinies, nursing homes, etc Worksite Location Brigham & Women’s Hospital Paget of 6 Date: ssr2011 Time: 9:57 AM.Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan S Friedes, M.D. License No.: 76365 Faulkner Hospital Harvard Vanguard Medical Associates Boston Harvard Vanguard. Somerville 11) Care of patients in Massachus Average weekly hours involved i a) inpatient care 24 nrsivk b) outpatient care 40 hrsiwie 12) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEnd Date —_Policy Type RICO o1orioa11 01012012 Occurrence Policy 18) Do you perform any surgery in your Massachusetts office? 14) Claims Made 2) New. Have you received notification of a claim, whether or not a lawsutt was fled on that claim, or has 2ty medal malpractice claim been made against you curing this time pened? ») Pending: Are there any unresolved malpractice claims against you today, le., any claims that have not been resolved, settied or adjudicated during this ime peroc? 18) Claims Closed Fas any medical malpractice claim against you (whether or not a lawsuit was fled on that claim) been Fesolved, settled, oF adjudicated during this time period? 16) Other Civil Lawsuits ‘Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine 2) New: Have there been ary claims, other than medical malpractice claims, fled against you during this ime period’ ») Resolved: Have you resolved, settled or acjudicated any lawsuits, other than medical malpractice Claims, dunng this period? 17) Criminal Charges 2) Have you been charged with any criminal offense during this period? b) Heve any criminal offensesicharges against you been resolved during ths time period? 9) Are there any criminal charges pending against you today? 4) Are any Application of Issuance of Process pending against you? 18) Other Issues, ) Have you withdrawn an application to any goveinmental authority, heath care facility, group practice ‘employer or professional assoc.ation? b) Have you ever taken a leave of absence from any healthcare faciity, group practice or employer? ST ec Sera eee Erm tea grace, Massachusetts Boars of Regstration in Medicine or ary other state medical board, health care fact, JTOUp practice, employer of professional association? 4) Have you been the subject ofa disciplinary action taken by any governmental authority, health care facilty, group practice, employer or professional association? 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by or surrendered to any state or federal agency? allowed a license application to 20) Have you withdrawn an application for a medical license, 1Se for any reason? become obsolete or have you been denied a medical lic Page2 of 6 Date: sitsr2011 ‘Time: 9:87 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathen S Friedes, M.D. License No.: 76366 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge ‘or co-payment, or placed any condition related to professional competency or conduct on your ‘coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in response'to an inquiry by a medical liability insurance carrier? 22) Have you completed all CME requirements (100 hours of CME of which 10 hours must be in risk ‘management. Requirement: 40 hours credit in Category 1 and 60 hours in Gategory 2) for this, Yes renewal period? (If you are in an approved Residency! Fellowship program, or if your are renewing your license for the first time, please answer Yes) Page 3 of 6 Dete: snsr2014 Tims: 9:87 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application me 24) Have you used any chemical substance(s) which in any way interferes with your ability practice medicine? License No.: 76265 u have a medical condition that interferes in any way or limits your ability to practice ine? Page d of 6 Dat: ts/2011 Time: 9:57 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan S Friedes, M.D. Current Status: Active License Expiration Date: 9/25/2015 1) Activity Status: Active 2) Address & Contact Information Mailing Address: Harvard Vanguard Med Associates 183 Brookline Avenue Boston Massachusetts - 02215 United States of America Home Address: Business Address: Harvard Vanguard Med Associates 133 Brookline Avenue Boston Massachusetts - 02215 United States of America (617) 42-1191 3) Email Address: 4) Fax Number: (617) 421-5828 5) Specialties Obstetrics and Gynecology 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMSIACA Board Name Certification Subspecialty ABMS Obstetrics & Gynecology ‘Obstetrics and Gynecology 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed California Hawai 10) Work Sites Wer Sil vork sites in Massachusetts, including health care facilities (where you are credentialed), private office, clinics, nursing homes, etc Worksite Location Beth Israel Deaconess Medical Center Paget off Date: 1812015, Timo: 4:25 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal App! Physician Name: Jonathan $ Friedes, M.D, License No.: 76366 Harvard Vanguard Medical Assoc. Kenmore Boston Harvard Vanguard- Somerville 11) Gare of patients in Massachusetts Average weekly hours involved inpatient care 24 hshvk 'b) outpatient care 40 hrsiwk 12) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEnd Date —_Policy Type RICO 0107172015 1278112015, Claims made with tail coverage 18) Do you perform any surgery in your Massachusetts office? 14) Claims Made aa) New: Have you received notification of a claim, whether or not 2 lawsuit was filed on thet claim, or has ‘any mecical malpractice claim been made against you during this time period’? bj Pending. Are there any unresolved malpractice claims against you today, Le , any claims that have ro" ‘been resolved, settled or adjudicated during this time petiod? 16) Claims Closed Has ary medical malpractice clsim against you (whether or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during thi time period? 16) Other Civil Lawsuits ‘Question 16 fefers {0 claims or actions related to your competency to practice medicine or your Professional conduct in the practice of medicine. 28) Now Have there been ary lati, ther than medical malpractice claims, lec against you curr tis time perio b) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during this perioa? 17) Criminat Charges a) Have you been charged with any criminal offense during this period? b) Have any criminal offenses/charges against you been resolved during this time period? ©} Are there any criminal charges pending against you today? ) Are any Application of Issuance of Process pending against you? 18) Other Issues SihBve you withdrewn an appication to ary governmertal suthory, heath care facity, croup practice ‘employer or professional association?” by Fave you taken a leave of absence from any heelth care facilty, group practice or employer for reasons related fo your competence to practice medicine? o} Have you been the subject of en investigation by ary governmental authorty, including the Massachusetts Board of Registration in Medione or ary oft state mecca board neath care faciy, group practice, employer or professional assocation? a) Flave you been the suject ofa disciplinary action taken by ary governmental authoiy, health care facility, group prachoe, employer o professional association? 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by of surrendered to any state or federal agency? 20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete or have you been denied a medical license for any reason? Page 20f8 Date: a 972015 Time: 4:25 PMCommonwealth of Massachusetts &®) Board of Registration in Medicine Physician Renewal Application Physician Name: Jonathan S Friedes, M.D. License No.: 76366 21) Has any medical liability insurance cartier restricted, limited, terminated, imposed a surcharge ‘Or co-payment, of placed any condition related to professional competency or conduct on your Coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in Tesponse to an inquiry by a medical liability insurance carrier? 22) Have you completed all of the CPD requirements for this renewal cycle? If you are renewing your license for the first time or participating In postgraduate training, please answer Yes. Yes Page 3of6 Date: stsr2015 in: 4:25 PMCommonwealth of Massachusetts Board of Registrat Medicine Physician Renewal Application Physician Name: vlonathan S Friedes, MD. License No.: 76366 23) Do you have a medical condition thet interferes in any way or limits your ablity to practice medicine’ 24) Have you used any chemical substance(s) which in any way interferes with your ability to practice medicine’ Page 4 of 6 Date: ssi201s Timo: 4:25 PitBoard of Registration in Medicine Physician Renewal Application Physician Name: Jonathan S Friedes, M.D. License No.: 76366 ) Commonwealth of Massachusetts 25) Electronic Health Records Proficiency | Nave demonstrated proficiency in the use of EHR by participation ina Meaningful Use program as an eligible professional 28) Requirement to Complete Training in Recognizing and Reporting Child Abuse Have you completed training to recognize and report suspected child abuse or neglect? Page So Date: sasr2015 Time: 4:25 PMCommonwealth of Massachusetts Board of Registration in Medicine 10 West Stroot Boston, Massachusetts 02151 mise ee es 16171727 3086 oA Oaman Fan. (6171 457-9568 WARY ANNA SULLIVAN, MD {Consuela an Business Rey teense svexanon Free ARNOLD $ ELMAN, MD Peneiore WELLS FEVER N, MADRAS, M.D REDACTED Copy “sttatm® May 19, 1998 Jonathan S, Friedes. MD Re Docket Number 97-393 Dear Dr. Friedes The Complaint Committee of the Board has considered the above referenced complaint and has determined that no further action is warranted The complaint has been dismissed ‘Thank you for your cooperation in the investigation of this matter” The Committee appreciates the time and effort which you expended in preparing your response. I! you have any questions, please feel free to cali me at (617) 727-1788, or write to me at the above adcress. Very truly yours / Vo dX 6 / Aidt A Ee Marylee /)- Consumer Protection CoordinatorCommonwealth of Massachusetts Board of Registration in Medicine 10 West Street Boston, Massnchusetts 02111 SHAN 4, ECE, 9. tein 727-2086 com sare Fax: (617) 451-956 MARY ANNA BULLIVAN, 1.0, «aha Aganey within hn Ole of Censumar Atak ane Buna Moyuation teeananr ALEXANDER F, FLEMING ARNOLD §, RELMAN, MD. PeweLore WELLS PETER N. MADRAS, M.. WALTER 8. pRace May 19, 1998 Re: Jonathan S, Friedes, MD Docket Number: 97-393 Dear! ‘The Complaint Committee of the Board of Registration in Medicine has carefully considered the information you furnished it regarding your complaint against the physician referenced above. A copy of your comptaint was sent to the physician, who was required to respond in writing to the Board regarding the issues you raised. After a thorough review of this evidence, the Committee determined that your compiaint and the physician's response should be piaced in the permanent Tecord of the physician. While the Committee declined to recommend the iniliation of formal disciplinary action in this case, it is appreciative of your actions in bringing this matter to its attention. ‘Should you have any questions or additional material which you wish the Board to consider, please write to Mary Lee, Consumer Protection Coordinator, at the above address. ‘Thank you again for your concern, Very truly yours, _ ass Age. Marylee // * ‘Consumer Protection CoordinatorALEXANDER F, FLEMING Lye. amonwealtn or Massacht tts Board of Registration in Medicine 10 West Street Boston, Massachusaits 02111 ni (61) 727-3088 Miao (617) 451-9568, MARY ANNA SULLIVAM, MO. ‘hn Agency within he Othe of Consumer Atte end Buxnete Aoguelon ‘rane ARNOLD 5. RELAY, 18.0. toaoun eacumve onecTON PENELOPE WELLE even w. maonas, ‘omens ect. ‘amo meen December 29, 1997 Jonathan S.Friedes, MD Re. Docket Number: 97-393 Dear Dr. Friedes: The Board of Registration in Medicine has received a complaint regarding your conduet in the practice of medicine, a copy of which is enclosed. The Board Js obligated by law to investigate such matters relating to the proper practice of medicine. In compliance with this mandate, the Board's Complaint Committee has directed the staff of the Board to gather information on all such complaints. Please provide a written response to the issues raised in the enclosed material. Your response may be as brief or as lengthy as you choose. Under the law, the person filing the enclosed complaint may have access to your response. Your response should be sent to the Consumer Protection ‘Coordinator, at the address above, within 30 days of your receipt of this letter. After your response is received, the case may be assigned to an investigator employed by the Board, who may contact you if further information is needed. You will in any ‘event be informed in writing as to the disposition ‘of this complaint, Thank you for your attention to'this matter. Very truly yours, Charlene Morelli Compliance Officer Lp exes nsec one:camonWwealtn OF Massacn — 2UtS Board of Registration in Medicine 10 West Street Boston, Massachusotts 02111 Te (617) 727-9086 CARL M. SAPERS Fox: (817) 451-9668 eee ‘an Aguney witin the Office of Consumer Attia and Business Ragsteion ALEXANDER F. FLEMING PENELOPE WELS. ‘sna course. December 29, 1997 Re: Jonathan S. Friedes, MD Docket Number: 97-393, Dear . Your complaint regarding the physician named above has been recelved. The physician involved has been asked to respond in-wrting to your complai Any future correspondence regarding your complaint should include the name of the physician and the complaint number as it appears in. this letter. Ifyou wish to bring additional information bearing on your complaint to the attention of the Board, please furnish it in writing to the Consumer Protection Department at the address above Very truly yours, Charlene Morelli ‘Compliance Officer Ch instr eee oeVy Harvard Vanguard Medical Associates A major teaching afiate of Harvard Medial School January 30, 1998 Charlene Morelli Compliance Officer ‘Commonwealth of Massachusetts Board of Registration in Medicine 10 West Street Boston; MA 02111 Re: Docket Number 97-393 Dear Ms. Morelli: Ihave reviewed the complaint form submitted by : as well as the copy of the letter dated 11/24/97 she sent to the Somerville Health Center of Harvard Pilgrim Health Care (HPHC). There are several points which warrant a reply. “The complaint form refers to “breach of patient confidentiality”. ‘The telephone call to -mother was accidental. HPHC has two computer systems which contain patients’ phone numbers, One of these contained out- dated information. At some point had given her mother’s phone number as the number at which she should be reached, and this had not yet been updated. Although I cannot remember the exact details of each phone call I tried to place to it is quite possible that I did not have in front of me the slip of paper on which the medical assistant who had taken her message had written her number, In such a case | would have used the phone numbers printed out ‘on the lab results form or loaked her up in the computer, and in this way, obtained the incerrect number. apparently reported that the message I left on her mother's machine referred to “negative cultures”. I do not leave explicit messages (such as, "Your herpes culture is negative”) unless a patient has clearly told me that this is all right, In some cases, particularly if a patient has been hard to reach and/or anxious, | may leave a message that is vague, but still has some content (such as, “Your tests are OK”). Two months after the fact 1 do not recall whether had given me permission to leave an explicit message at her number or whether she regards even the latter sort of message as “detailed”. Regardless of Kenmore 132 Brookline Avenue (617) 421-1000 Boston, MA 02215 woruharardvanguardorgwhich explanation is correct, { in no way intended to disclose any sort of medical information to anyone other than and I certainly regret any discomfort that any disclosure, regardless of how oblique, has caused her. ‘The complaint form also alleges “professional misconduct”. 1am assuming that is referring to her concern, voiced in her letter, of 11/24/97, about my “bed side manner”. When Isee patients, I generally talk about my assessments and management plans right after I have examined them, unless | need to leave the room (for example, in order to examine a wet prep under a microscope or complete an ultrasound requisition). shad many questions and concerns about herpes infections, and the discussion went on for quite some time. | was not aware of any emotional discomfort on her part during our discussion. She even returned a few minutes later with a couple more questions, and [ spent more time answering these. in short, I interacted wit! in the way I interact with all my patients. 1 am nevertheless sorry she felt uncomfortable, and I beliove that my letter of 12/26/97 (see enclosed copy) expresses this best, Concerning the allegations of “substandard medical care”, “failure to send urine to lab” and “failure to request more tests ie. STD”, | must disagree completely with ‘The symptoms she described to me (such as external burning with urination and vulvar pain) and, in fact, the symptoms she had described one day earlier in a phone triage message, are far more consistent with genital herpes (HSV) than with a urinary tract infection (UTI). ‘The tender ulcerative lesions she had on the labia minora were typical in appearance for herpetic lesions and entirely inconsistent with the diagnosis of a UTI. The negative HSV culture does not necessarily mean that did not have HSV, as there is a 10-20% false-negative rate. subsequently followed up with her usual gynecologic practitioner. ordered serologic studies which were positive for exposure to HSV. ‘This strongly supports the conclusion that the symptoms and labial lesions were, in fact, herpetic. The urine culture ordered by which showed 25,000 E. coli/ml., does not necessarily imply a clinically significant UTI; such colony counts are often associated with asymptomatic colonization, and may well have been a totally incidental finding. sand I did discuss testing for other STD's. Performing a speculum ‘exam to test for gonorrhea and chlamydia cervicitis would have been extremely painful at the time of that appointment, and, according to my notes,. _: also declined other STD testing (e.g. RPR, HV)that day. also alleges “patient neglect/abandonment” on the complaint form. 1 cannot fully address this complaint, as [ 4a nat understand it. As noted, shad appropriate follow-up with Twas also incommunication with rafter she saw - and was also able to verify her care in the medical record. Finally, in the complaint form, indicates that I had been contacted about her complaints, and there is the implication that I had been unresponsive. While she did, in fact, speak to Doctors ” 4 (the head of the ‘OB/Gyn Department at the HPHC Post Office Square Center, where the appointment in question took place) and | {Chief of Operations, HPLC Division of OB/Gyn at Brigham and Women’s Hospital), she never contacted me directly. She did not convey any concerns in our telephone conversation of 11/18/97, one week after the appointment. | do feel that had she communicated her concerns to me at some point it might have been possible to dal with them before they escalated. From my initial conversation with . in which she relayed complaints, it was my impression that she did not wish any sort of communication with me. Subsequently,, and} spoke, and requested apologies or explanations from me on two points. (I have enclosed a copy of L letter to ) Asa result of their conversation I sent fa letter, a copy of which is enclosed, which, I believe, addressed those concerns. Please let me know if you need further information, Sincerely,Lununonwealn OF Massachuseus: Board of Registration in Medicine 10 West Street Boston, Massachusotts 02117 ‘an agnay ain tno Oo Cerri ne ates Pogaion ALEXANDER F FLEMING. 3.0, ovetore wet an COMPLAINT FORM Please ‘or print clearly, and provide all of the information requested. eon feet OM. Your FirstName Last Name Patient Name (If different) s. fom Pee ee eee eee eee ‘Street Address Mailing Address (if different) City © Bate Zip Code Busifess/Daytime Phone. Atiome Phone ‘Complaint against M.D. >=, D.0. ‘Acupunctirisi____. (For complaints against Chiropractors, Dentists’ Nurses, Optometrists Podiatrisis or Psychologists, please contact the Division of Registration at (617)727-7406, or 100 Cambridge St, Boston, MA ed “This complain cannat be processed without the full name of de physician or acupuncturist. Please verify Pull Name (Eicsi & Last) of Physician or Acupuncturist (one name per form) Photocopies are acceptable. — Address AUP ZOs7 Los Fear LEZ Lethe See City ‘State Zip Code 2a 6205-H0F- Busts Bhone Pe £O | Name and Location of Health Care Facility (if known) LPM Bist bie Sauce Rature of Compinint Substandard Medical Cae, Dug Deating (BF Profesional Miscnduet _criminst Convition TD sexual Misconduct EP Prien NoglevA bandonment C—_Rude or Discourteous Behavior 1 Unlawiut Diserimination impaired by Alcohol or Drugs C__illig for Services Not Rendored 1 tmpatred by Menial or Emotone less CD —Fallureto Supervise Stat D _Raiture wo Provide Mecca! Records D Fale Advertsing CG __Overcharge far Media! Recorés O Fraud Other ebre_fo Stxtl teint fo heli, belted. oP car, uh aad ale, © tale Ue 14 ryailure ta complete nnd sign ths release may prevent investigation of your complaint, Release of Medical Records and-Information “fe Patient Navne: _ Date of Birth Address: oe. a — yout. c fH = fh’ AUTHORIZE ANY AND ALL: HEALTHCARE PROVIDERS OR INSTITUTIONS TO RELEASE ANY AND ALL,OF MY MEDICAL RECORDS TO, AND TO DISCUSS MY MEDICAL CARE WITH, THE MASSACHUSETTS BOARD OF RE@TSTRATION INYJPDICINE, Signature of Patient: _ Date: LULEL ID. (Or Legat Representative) trurrien aumiontZe my Sina HEALTH PROVIDER(S) TO DISCUSS EVALUATIONS, DIAGNOSES OR TREATMENT AND/OR RELEASE ANY AND ALL OF MY MEDICAL RECORDS TO THE MASSACHUSETTS HOARD OF REGISTRATION IN MEDICINE. THIS AUTHORIZATION REPRESENTS A WAIVER OF THE PSYCHOTHERAPIST-PATIENT PRIVILEGE, AS DESCRIBED TN OL. . 233, 208. signature of Patient: ALP. Dae: (Or Legal Represemiative) Peas st eats ad adciee of ul eae provide and insta th provide einen wich Dette LPP. v0 Mlbal St, Sanaa Lb td dtd ‘you arent patient, what is your elainship tothe patent? 1 Spouse, Paren, Ci chil, C) Other Relative CO Frsad, C Awomey, Cl other tas this physiean provided weauret in the pas? (Do not coun ie Beatment inthis complaint) TD Ves, GE ipa i eon uri ay ve your tee i Yes, ; How tong have you er pte) been under his physician's are? ‘30 days, C1 1 to 12 months, CJ 1 to 2 years, C1 2:0 4 years, 2 410 8 years, D8 years or more wna im of poyment vas made? Check a many a5 epry. Cl Commercial insurance, C) Health Maint ance Organization, CI Mgficald, Medicare, C1 Champus 1 workers’ Compessusion, O Self, $2Bther, : ‘Are yoo (6 patient) expected o pay a portion ofthis bitZout of packer? Oves, ‘asthe physician adjusted the bill ia any way, for example, was the fee or copayment reduced or O ves, _ Is te fee or nt in dispute? a ‘es Po as the physica been contacted about this complaint? sleet, 1, {G62 2M LELM,Describe your complaint here or attach, If you need more space, continue on reverse oF on another sheet of paper. 1 eae copie Tae doce to Tor {fhe tormation in his comping pre, coment ond egspe othe best of my knowledge Your signature: _ Mail this fof to: “ Consumer Protection Coordinetor Board of Registration in Medicine ‘Ten West Street, Thitd Floor Boston MA O2111online ete nz bored arb November 24, 1997 Administration Harvard Pilgrim Health Plan 40 Holland Street Somerville, MA 02144 Matter: OB-GYN visit with Dr, Jonathan Friedes Dear Sir or Madame: Jam writing to address my concems regarding my visit with Dr. Friedes at Post Office ‘Square on Friday, November 14, 1997. { had called Urgent Care Thursday night complaining about the discomfort | had while urinating. | was advised to have an ‘gynecologist examine me. Friday morning | was able to make an appointment at Post Office Square OB-GYN after speaking to a nurse in detailed about my situation. I would like to address some concams | have about my visit with Dr. Friedas: 4. His.bed side manner. After he briefly examined me and his assistant left, Or. _. Frledes continued to talk.to me although | was not fully dressed, | felt awkward asking,"Is this examine over? May | get dress?" | have never had to ask & physician that particular question before nor did | fee) comfortable at the time of my visit. His mannerism was very unprofessional and out of line. 2. His prompt diagnose after examining me briefly. Al the time of the ‘examination, | did not know what to say in regards to his medical diagnose. | ‘was skeptical because | lack knowledge of the virus, He did not rule out other possibilities before stating. such a diagnose. He did not explain to me the symptoms of the virus or other information relating to it I wanted a second opinion on the diagnose because | was very concern. | went fo see t my regular gynecologist, on Tuesday, November 18, 1997 at the Somerville Genter. . examined me very thoroughly and ran some tests to cover anything Dr. Friedes could have missed. We had discussed at length my concerns regarding Dr. Friedes’ diagnoss.. It wes difficult to get a second opinion on the matter because Lwas 100 far along in my.treatment. We had to wait for Dr. Friedes' lab culture to come back. roMy mother received a phone from Dr. Friedas at her home Thursday and Friday - afternoon. Both times she gave him my home and work number. Then she procesded to call me at work because he had called twice and she was concerned about my visit. She had me listen to the message from Dr. Friedes. | heard the DETAILED message from him. | thought all visits and anything that transpires between physician and Patient was to be kept CONFIDENTIAL, | was also under the assumption that there was a standard message for HPHP to leave on a machine of their patients. 1 am outraged by the lack of professionalism and his phone call on Friday, November 21, 1997. | hava given him my home end work number on November 14, 1997, he was able to call me both at home and work on Friday. He was also anie to reach me at work on Tuesday, November 18, 1997 after my visit with ack to see how the mossage was not passed on clearly as fo where he can reach me. { called Dr, Friades' office to resolve this matter and had also called _ >ffice just in case they were also looking for me. | spoke with a nurse in OB-GYN al the ‘Somerville Center at about 4 P.M. She told me personally that all the lab work from ‘Tuesday, November 18, 1997, looked fine and that | had a urinary tract infection-Not a VIRUS. | became enraged because during my visit with Dr. Friedes | gave a urine sample and | cannot believe he neglected to test my urine, His negligence caused me grief mentally, emotionally, and physically. I would like an explanation for his insufficiency and lack of professionalism. | would also like to know how Harvard Pilgrimage Health Plan intends to regain my trust end confidence in their physicians. | would like to have this matter resolved as acon as possible. If you have any questions or need further information, please feel free to call me at ‘Thank you for your tims and attention to this matter. Sincerely yours, - Post Office Square HPHP