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ODES cc wih Bou hs owaetnay Kiamurceay Dodou Ao 25 tone thee Soom f SShaarsubeusy 03 aw ordumeten Boyeesoey Pal Bone Pt ne brs Silugciertrecslangey GF _ Rawsrooumaoay me S sccactonmaey 9} Soaeocemede sey ; Ey GeedetEnrgmoytindeen «OTs eres 3 fe Scaaaremh races Pi Soucereenseny ‘ Reeaatrmmaricta fe touasteedures v MS Eexcchieroega poy Fam bor pe Mace anoston "serene Fee coee OL [OO n fecty ode ny coe — ‘sty eee ~~ 1109 woe nara 11.2) Anal spans a eh yu nll poieges andor Heh Care Fain wih woh you nee aod nf (See Tews) Frey once Fay Cos: Fc Coe: Foy Coon Pay 1628 wre Na: * rey arty tat treunnog MACTVE states Wl no praaee mado In Masachutt srnant to MG. 6475, wt at charge oo cle tom a Medere bnwtry mor than the Maire reatonahe charg fr my sees, ag Ronee amny dra ates Pet at ea RAB pi Boo yes cea aout te ey ‘ray ery unr he pare perry tha al lnlormaen cole lom-entend bach and eh stead pagan ia oe won Betsey Qagunt 4.0. mn 24SMaseachusete Boars of Hogi lon a Medicine 1989-1901 Renewal Application, Page 2017 ‘vi nae at aurea. Physiclon Last hare: ti Cc aetna 12 8) Oe Sates whne yous nw cane orate Arise 12.2) Sate wher yup wierd pace tort) 18 tam apn be gid with a folowing sit ome 7 “NCI YA am cs oh 4 a hue emp ny CRE. autem the ta re and on eC at lia FIN # a nurar pe ec) Oech ae) Coupon has Caogay the. (aenegrnt hel Passony Progam ts 11. ‘ave Pai" You mut Lae sopte We Form) 14 bay nade alos onan coved Wy INSURANCE CARRIER LETTEROF CREDIT. Yaplcabl check nw a Ho tne Mines Pega Li DeH Liesttare ssa’ hatcon aei09 Leer et ‘cay ate eo: ase KET bl ae tse NOTHNRED NORECT/NDFECTPRTENTCANC OMERNSERSEMPTED. ut foo) Paseo Pcie in nance: (Q2_% urs 1s rough 7 wes ga ry on, Cech tr YES er MO nt W/o nao, Poids Fm A anaehed ‘5 tae any pening or aoe risel mapt cin buon made gua eh er nat a wa ain aon ee fay bar ala! any erg sm cin rcedig Ob an it Wl cane? ee ry ceca cage msenisasiinetrtnses ana ‘gaan avec conestsnt Searca ‘you sneer YES to qwsion 15, 16,01 roid 08 Form 15, tach econ 8 og 24 tr tre cal CheckeltarYESerNO (aa eschqusion rokt ovate meet scton Yes Ne mee tinea ec tr Se ea es eg Mt 1} you tadary mana naan es gate you any opie madlone o' faeon as MC a ane? 2. Ns ou MM AN gH es ch a np your ay Ipeaee mace rouse A ato mas. £2 fen yourow rho you bun in he ps caponentupon hee ge? £5 en yous ay ser, et nn Sony Mt Cetin. fh you O06 doa wearsaaon Dyan of oe tesa Bowe? HS ot owe:“per st Ce THE COMMONWEALTH OF MASSACHUSETTS Approved: BOARO OF REGISTRATION IN MEDICINE Disapproved Application for Endorsement Registration - NATIONAL BOAROS (Fee- $150, must accompany APPLICATION - No currency or personal checks) FOR OFFICE USE Application # &3/% certificate ASG44-F ate of tssue: 5/ name. BETS S Preevsi Mailing Address: _ Huu eee rae, Last Date of Birth (el5@ Place of Birth Naw Yori. Name on Biren Certificate Beisc4 Sue Aroubinone + i Pre-medical Education Pesca | Medical Education Scnoat Frown Unt wersi bay Wedicmrelsenoo! Buss Vriucysihy Rexramare Meera male Dates Accented W]tle — Jeu BO pares Artenced Vesdly 1180 ~ June (79 POSTGRADUATE EDUCATION ANO HOSPITAL APPOINTMENTS Place Position Stas Zi Bryce. Keil cal euler, Resisttal ohsebres eutl Oyneuilog, ily BY: sue 1988 List all other states where you are or have been licensed: Jt Are you a Diplomate of a Specialty Soard? No Trane, TF applicabre)Co soyeEAUTH OF MASSACHUSETTS FOR OFFICE U: SLY BOARD OF SECISTRATION Th MEDICINE Fall License ss ;breatson SUPPLEMENT TO APPLICATION FOR Pendsre Approved FULL LICENSE License TOE RL YA sane: “Being fu, PenmAATRT AgDRE hake Mads cab lerter Local, marLise ADDRESS 18 (Ma): YOU ARE FEqUITED TO COMPLETE THE QUESTIONS BELOW. 1. Hes any practice claie ever been you tthe 1 reu(uhether of nots laveurt vas filed in relation to the clase)? 1 2t “fave you ever Deen densed the right to participate or enroll ih any syeten wheresy a thir party pays ell or part of patient's Ball? 2 3. have you ever applied for licensure or to sit for an eionsnation of token an exaeination, under @ different na 3. se fave you ever been denied the privileges of taking or Finishing an svaninaeson oF neon accused Of cheating and/or improper conéuct during an examination since your matriculation a tion) Before any 5 6. "Have you ever been denied s aedical Iicens ted ot temporary, for any ressoo? 6 Tr" MMave you ever had staff privileges, exployaent or eppointne: in a heapital or other health core anstitution, deniee, auspensed of revoked, of resigned froe 0 wedical etaff in lieu of Gisciplinery accion? n 8. are ony formal disciplinary eh pending or hae any disciplinary ection been taken against you dn the act ten years by any governmental sutnority, 0) any hospital of health cave facilicy, of by eny professional wedical aesectatso, (international, national, or local)? 8 oo fave you ever voluntarily wurrendered « License to prac , The Board's regulations Getine “disciplinary action.” Please refer to 243 CMR 3.02, : attache 10, “Have you ever withdravn an application for aedical Iicengure, hospitel, priviteages of appointment, for any reason? 10. LiS""fave you ever {or any resson, lost huerican Specsalty hoard: Certification? Tis “Here you been denied required recertification by one or aore specialty boores? 2 yes, whieh nea)” T3r" fave you atvany tines been o defendant te any erintnel teeceeding’ cther chin ‘eine attic offenses? ae is. ‘las Jour privilege to porseas, diapente or prescribe rolled substancets ever been ded, revoket, dente surrendered or have you ‘shied Store this state or any other Jursegiction includtog sey atiany © 1 isi “ate forever nad any sectioned atsturtence ot ilnees wrleh, hes dmpastee Your ability te practice or tatfunctson'ae avttedene of wedicing? Tn 1s. 16, “Shave jeu ever nad av organic Aiiners which has Jour AUsLAty ce prattiee’ andicine or to fonction as + eeedent Sf aedieine? ee 6. TT TEE yo0 mow, or have you been in the past, dependent upon > 4 ae alconel oF druge? Je. "Have you ever held s license in Massachusetts or any other state or country? If yee, lise other juriedictions. NOTE ON QUESTIONS 15-17: The harm chat befalls phyatedann and patients Eapsiznent gore undetected and untreated by the medical prof ‘The Bosra vance impaired phyeieians treated in che early etage Etreperabie hore ro the physician or patient cocure. TE Jou have anavered "yes" to any of the above except #18 ple: reverse aide. Attach adaational @ 1/2" x 11" sheece af 243° CHR 1,00 enrough 3.00.” Tot 2 for Full Licensure sa Mi expigin on the wall or 1 nerety certify under th ity of perjury that a1) information en this fore i (front an back) including attached sheets ae true, wrcesrne, “Kahrs (Bud une WO sure, fed IBFS P THE COMMONWEALTH OF HA 7 VS } \SSACHUSETTS = ft BOARD OF REGISTRATION JN MEDICINE 55467 S-/p- § APPLICATION FORLIMFED-REGISTRATLON4 FELLOW ~ -(Eee-of $25.00 must accompany application=no currency of personal checks) 9% FOR OFFICE USE vate Received 3:5. B'. Certificate #_ P23 py: KW Form of Fee: SHO FOREIGN MEDICAL GRADUATES MUST SUPPLY A NOTARIZED COPY OF ECFHG CERTIFICATE. IF NO PREVIOUS LIMITED LICENSE HAS SEEN HELD IN MASSACHUSETTS, SUBMIT A NOTARIZED PHOTOCOPY OF THE INTERIM ECFNG CERTIFICATE. A NOTARIZED COPY OF THE STANDARD ECFMG NUST BE SUBMITTED WITH FIRST RENEWAL. SECTION A: Sworn statement to be completed by applicant, Please tvoe or print. Name:__ Betsy sue __ August Mailing Address: ~ _ Fret Madre tas see Date of Birth: - Pre-medical School: Brown University [neaicer School: __Brown University Program in Medicine Have you ever held a previous LIMITED REGISTRATION IN MASSACHUSETTS? es_ 88171 ave rant esr) Have you ever had any medical license revoked, suspended or cancelled? Have you ever been denied a medical license? Have you ever been denied the privilege of taking an examination before any State Medical Board? Have you ever failed an examination before a State Medical Board? Has your privilege to possess, dispense or prescribe controlled sub- stances ever been suspended or revoked in this state or any other? Have you ever been warned, censured, had your privileges restricted or been requested to withdraw from a hospital staff? Have you ever been a patient for the treatment of @ mental illness? Have you ever been under treatment for drug dependency or alcoholism? Has a judgement ever been returned against you in a malpractice suit? Have you ever been convicted of any criminal offense other than minor traffic offenses? If you answered YES to any of the above questions, please provide a deteiled statement. SIGNATURE OF APPLICANT: Bets Auduak WA pate: 12[s0(B& _ SECTION B: To be completed and signed by the Superintendent or Administrator of the Hospital in which the applicant has received an appointment. This certifies that _ Betsy Sue August has been appointed to the position of PGY-4 Hospital Medical Officer in Baystate Medical Center _ (Name of Hospi tat) beginning duly 1, 1987 and ending ‘June 30, 1988 a : Is the purpose of this application participation in a training progran? (yes or no) (yes or no) If the program is not If yes, is this program ACGME or RRC accredited? 50 Jecredited (ive. fellowship), does your institutTon have an ACGME or RRC accredited residency training program in the applicant's specialty? __ (yes or no) Velen MA Vice President, Academic Affairs 2/24/87 Tal Bthel Weipherg, M.D. OFFICIAL CAPACITY ATE ALL INFORMATION SUPPLIED CONSTITUTES A TRUE STATEMENT MADE UNDER PENALITIES OF PERJURY.Commonwealth of Massachusetts Board of Registration in Medicine i ‘560 Harrison Avenue, Sulte #G-4, Boston, MA. 02118 — (617) 654-9810 btip://www.massmedhoard.org\ Physician Registration Renewal Application e need coples for credentialing and other purposes, reen envelope at least 4 weeks before your renew Renewal Date05/19/2003, 1, Current Status: Active Registration No 59447 ‘ifyou want to change your current status, please check one of te following boxes to indicate your yew status: (Check only one) Dactive Ci Retiring (see instructions) Ci inactive (see instructions) [Do not wish to renew 2. Other Name(s), if any, under which you were licensed: eae ons (print) A) Mailing/Business Address: TOther Name(s) C] Name Change (enter name below) 3. BETSY s AUGUST 400 HIGHLAND AVENUE Mailing Address: SALEM, MA 01970 City/Town: (2, eeeaaststeain gee B) Home Address: Business Address: CtorTow: Site Zip: eae De Teens (498) TH= RIGO [Home Address Home Phone: spre County i eas ‘Telephone: He Peete Business Phone : Only ang address can boa P.O. box. The mailing addres cannot be a P.O. Box. 4. a) Date of Births b)Sex—F | 7, Curent American Boatd of Medical Specialties Certification (Sc Tabie2) oe Code: 06 Code: 8.Drug License Numbers, ifanv: 5. 8} Name of Medical Schoo! | ’)) Federal (DEAY. Brown University School of Medicine yeaa by Yeer Graduated Degree: # 3984 ) DEBE: aap, 9. a) Other states: hactid etd Abbr.) 6. Speciaty Code(s) (See Table 1) Ws ) States where ver jously licensed (Abbr) ‘OBG 40 rics und Gynecology >) States Where you were previc yusly Hicensed ( ) a 10, List all 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 piace # check mark next to those health care facilities where you have admiting privileges (AP). [Next to each facility, write the approximate percentage of patent care hows that you provide in each facility). __ No affilitions. % Facility Code: % Facility Codi % 5% Facility Code: %% Facility Code: LM ay) ¢ i ar) $ Facility Code: 5. Facility Code: | le 1999, print name)PRINT YOUR LAST NAME: AVOUST LICENSE NUMBER: _S4¢¢ 3%: ~ 11, My medical malpractice insurdnce is covered by Insurance Carer) Leterof Credit 4, Alternatively, indicate as follows: I am registering with Active status but J am not covered by medical malpractice insurance ‘because Tam: Check One: {1}| Not involved in diectindioct patient care in Massachusetts [[] A goverament employee, otherwise exempt Please explain exemption: 12, What is your principal work setting? (See Tabled) A _© _ — Wyouare affiliated with « healthcare facility or credentialed for the provision of patient cae you must complete question #10 on page 1 aud list your affntons. 13, Care of patients in Massachuseta (cee instruction bookle). 1) Average weekly hours inyolved in: A) inpatient care ZO breiwk B) outpatient care /o() bis/wk 2) What isthe approximate of your patient care hours in primary care? /0O % O THE PAST TWO ‘malpractice claim that has been made against you been settled, whether or not a lawsuit was filed in relation to the claim? 16. Has any laweuit, other than ‘malpractice suit, which is related to your competency to practice medicine, ‘ot your professional conduct ia the,practice of medicine, been fled against you or been cetted, adjudicated or otherwise resolved? | 17. Have you been charged with any ctiminal offense? 18. Have you beon charged with or disciplined for aay violation of laws, rules, by-laws or standards of practice of ‘any governmental authority, health bare facility, group practice or professional society or association? 19, Has your privilege to posses, dispense or prescribe controlled rubstances been suspended, revoked, denied, restricted by, or surrendered to any {tate or federal agency? 20. Have you withdrawn en application for « medical license or been denied a medica! license for any reason? ‘21. Has any professional liability Provider restricted, limited, terminated, imposed a surcharge or ‘co-payment, ot placed any condition|related to professional competency or conduct on your coverage, or have ‘you voluntarily restricted, limited or terminsted your insurance coverage in response to an inquiry by a professione! liebility insurance 22, CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date? [Z} Yes [] No (2) CME Waiver. CME waiver form) must be submitted at least 30 days prior to license expiration date. CMEEXEMPTION: Check one: [) Intctive satus C}Residency/Felowship taining (See instructions) ‘See Instructions for CME walver o} exemptions. Do not submit documentation of your CMEs with application, ‘+ Pursuant to GLL. c. 112, See 1A, Lunderstend my obligations to report abuse or neglect of children under G.L. c. 119, Seo. S1A. ‘and the punishment for failure to f. + Pursuant to GL. c. 112, Sec. 21 Will not charge to or collect from a Medicare beneficiary more than the Medicare fee schedule amount ' + Pursuant to G.L, c. 62C, 49A, I cortify that ! have complied with all laws of the Commonwealth related to the filing of ‘Massachusetts state tax returns and payment of ll Massachusetts state taxes; reporting of employees and contractors under GL. ¢. 62K; sud withholding end temitting child support pursuant to G.L. c, 119A. (See instructions). I hereby certify under the penalties of porjury that aif information on this Renewal Application, Part B and Form R {s true,Massachusetts Physician Renewal Application yysician Name; BETSY S AUGUST “License No.: $9447 PART A 4) Current Status: Active ‘Renewal Due Date: 04/21/2005 th Date | Ifyou want fo change your curentstaus, please check one ofthe following boxes to indeate your new status : (Check onlyione), (See Renewal Instructions, page 3.) OF Active | Retiring Inactive 1 Do nox wish to renew 2) Addresses & Conjact Information, Please confirm your addresses and make changes, ifnecessary. You are Fequired 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. Sates ea 28) MAILING ADDRESS | | 400 HIGHLAND AVENUE Meiting Address: ‘SALEM, MA 01970, City/Town: State : Country: 11 Otek ere change ts aie 2b) HOME ADDRESS jaca City/Town: State : Country Telephone: (__) Phone: ECEIV = DD Check here change tis fome address canner be a Post Office Box 2¢) BUSINESS ADDRESS “Address: 400 HIGHLAND AVENUE YAR 1 5 2006 iene: SALEM, MA 01970 Chpftowe Se: BOARD OF zi c esisraanoN MEMEO Ne ae PASTRATION Ot EDK Phone 78741-3700 } es Teepe: _) i Dy Check hereto change this oxdrese Business address cannot be a Post Office Box 3) E-mail Address: QPaxNumbers 498. Ful - 3326 a '5) Specialties (See Renewal isruptions, page 4) Delete? | Additional specialties: | Obsteuips and Gypecology 0 r : T a 7 7 oO 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information. ‘Gee enclosed instructions and Renewal Instructions, page 4) List Certifying Bopraty| beloy : ‘Update General Certificates and Subspecialty Certificates | ' below. Please add additional Certifications as required. | Board Name ABMS or AOA __|_ Certificate/Subspecialt Correct? Delete? oa Obstetrics & Gynecology x a Chee: o a L boo o 5 oo o o Page 1 of 5 iae Massachusetts Physician Renewal Application Physiclan Name: BETSY S AUGUST License No 59467 Please make corrections as necessary ‘(See Renewal Instructions, page 4.) 8a) Other states where you are now licensed to practice (Abbr.) 7) Drug License Nunibers, if any: 4) Massachusetts: SNA gee sae SERRE Federal (DEA): 8b) States where you were previously licensed (Abbr.) deral (DEA) XS: is your principal work setting? (See Renewal Insiructions, page 4,) incpal Work Seng: Partnership or Group Practice Change Please enter the approximate number of work hours at your prineipal work setti 5 40) List ati current Health care facilities where you are affiliated or have completed the credentialing process for the provision of patent are. (Supply the name ofthe health care facility from Reference Table § on Page 16 ofthe Instruction booklet), Next to each fact, write your staff eategory at that faelity (Admiting, Active, Courtesy, ‘Associate or Consulting) and the approximate number of hours of patient care that you provide t that faeillty. Include any afiitions with online prestrbing seviees or companies. Pease provide al information for addtional fuses ona separate shel, tnecesary. No Affiliations [) Please enter the approximate number of work hours for each Health Care Facility below: Ticalth Care Facity (See Renewal Isradtons page 4) Dele] caren STORY een ‘Massachusetts Generdl Hospital OD |cowtesy| iz Trt Shoe Medical Centr = Salem Hopital Admit ee 7 oO Ga oO o i Qo 11) Care of patients in Massachusetts (See Renewal Instructions, page 4.) Average weekly hours involved in: a) inpatient care 20 ws/wk Change to: hrsiwk D) outpatient core _60__ hrs/wk Change to Inrsvk 12) Medical Liabifify Insurance Information (See Renewal Instructions, page 5.) | My medica! ibility insurance is provided through: (check one) B Insurance Carrier (complete below) ‘Current Insuraneé Cerer: CRICO Change to: Policy dates: From 1/2/05 — To_JB/2L/25 (required) 1 Letier of Credit subject to Board approval (auach a copy) 1m not required to have medica} lability insurance because 1 a ' D1 1am registering with Active statu bu Check one; 1B Not involved with director indirect patient care in Massachusetts I Government Employee Federal Tort Claims Act (FTCA) 11 Otherwise exempt Please explain) Page 2 of 5 eee gi rs. Massachusetts Physician Renewal Application BETSY $ AUGUST License No: S944? hysieian Nan 13) Do you perfor any surgery in your office? (See Renewal nvructions. page) Yes —~No : es, pleage complete Form PCA-O “Oftice Based Surgery" In questions 14-21; the phrase “time period” refers to the following: alltime from the day you signed your last ficense renewal/application, to the day you sign this renewal application, inclusive. (See Renewal Instructions, page 5.) ‘You must check cither YES or NO to each question, Provide details on Form R if you answer “VES" to any questions, Refer to Renewal Instructions for additional information and definitions. ALL. questions in this section must be answered. YRS_NO 14) CLAIMS MADE | a) New: Has any medica) malpractice (aim been made against you during tis time period, whether or nota lawsuit was fled on that claim? | z ') Pending: Atethere any unresolved malpractice elsims againet you today, any claims that have not been finally settled of finally adjudicated? + 18) CLAIMS PAID as any medical malpractice claim agsinst you (whether oF not lawsuit was fled ov tha laim) been resolved, sted, oF adjudicated during ths ime period? 16) OTHER CIVIL LAWSUITS ‘Quetion 16 refers to claims of actions related to your competency to practice medicine or your professional cohduct inthe practice of medicine. 4) Now: Have there been eny lawsuits; oter than medical malpractice claims, been filed against you during this time period? b) Resolved: Have you resolved, settled or adjudicated any laveuits, other than medica! malpractice claims, during this time period? 17) CRIMINAL CHARGES 2) Have you begn charged sith any er ) Are there any erimmal charges pening against you today? «) Have any criminal offenses/charges against you been resolved during this time period? 16) Have you been;charged with or disciplined for any violation of laws, rules, by-laws or standards of practice ‘of any governmental authority, heelth'care facility, group practice oF professional society or association? offense during this tine period? 19) Has your privilege to possess, dispense or prescribe controlled substances been Suspended, revoked, denied, restricted by, or surrendered to any state or federal agency? | 20) Have you withdrawn an appiction fra medical license allowed a license application become obsolete or have you bedo denied a medical Fcbse for any reason? 21) Has any medical liability insurance carrer restricted, limited, terminated, imposed a surcharge or co-payment, or placed eny condition related to professional competency or conduct on your coverage, oF hhave you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by ‘a medical liability insurence carrier? 7) CME CERTIFICATION 7 2) Have you competed your CME regtement preceding your renewal ate? rs Ono by IF no, are yj requesting w CME waiver? Cy Check to request CME Waiver. CME waiver request form must be submited alas 30 days prior to your license expiration date Se Renewal Instructions, poe 8) €)Hyou ate exempt fiom CME requirements, check reason for exemplion. (See Renewal hniructons, page 8) CME EXEMPTION: (check one) C1 Inactive Siss £)-Resideney/Fellowship ta Page 3 of 5ae Massachusetts Physician Renewal Application Physician Name: BETSY § AUGUST License Nox 59447 vs z (B-Trove reviewed my Physician Profile a profiles massmedboard.org end confirm thatthe information is accurate 11 have reviewed my Physician Profile and attached a copy ofthe Profit with corections. (1 My status is Inactive and I do not have a Physician Profile. (See Renewal Insiruetions, page 10.) CERTIFICATIONS J) ceri that 1 have complied with my objigatons to report abuse or neglect of children pursuant to G.L,¢. 119, sec. STA, and | understand the punishment for'failureto comply, 2) | certify that l have complied with my obligations to report abuse or neglect of disabled persons pursuant to G.L.c. 19C, see. 10, and J understand the punishment for failure to comply. 3)1 certify that | have complied with my obligations to report sbuse, neglect or financial exploitation of elderly persons pursuant to G.L. c.19A, se. 15, and T understand the punishment for failure to comply. 4) certify that Ihave complied with my obligations to report the treatment of wounds, burns and other injuries pursuant to Ge, 112, see. 128, 1 5) | certify that! have complied with my obligations to report the treatment of victims of rape or sexual assault pursuant to GLe. 112, see. 124 122. ‘6)1 certify that} have complied with my obligations to report a physician to the Board of Medicine, pursuant 1o G.L. ¢. 112, ‘ec, 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) Leen that | have complied my obligatjons rlsted to charging and collecting fees from Medicare beneficiaries in accordance with the Medicare fee schedule; and ! understand my obligations under G.L. ¢.112, see. 2. 8) I certify that I have complied with my obligations to file Massachusetts tex returns and to pay Massachusetts taxes, and | ‘understand that, pursuant to G.L. c. 62C, sec, 49A, my license shall not be issued or renewed unless I make these certifications under penalties of perjury. 9) I certify that I have complied with my obligations related tothe reporting of employees and contractors pursuant to G.L, OE. 310) 1 certify that I have complied with my obligations related to the withholding and remitting of child support pursuant to GiLe. 119A. 11) certify that I have complied with my obligations to file an Incident Report with the Board when certain adverse events ‘occur in my private offic, pursuant toG.L. ¢. 112 sec. 5 and 243 CMR. 3.00 et seq, and I understand that the Patient Care Assessment (PCA) programs atthe health care facilities where practice report certain Major Inekdents to the Board, Under penalties of perjury, I declare that I have examined this renewal application and all its accompanying instructions, forms and statements, ad to the best of my knowledge and belief, the information contained herein is trie, 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. signe: Ben, Ds STW we: 3, 0H OS JAKE A‘COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING, FOR YOUR CORDS, FOR CREDENTIALING AND OTHER PURPOSES. Page 5 of §Dr. Betsy $ August Data biggyse Number: 59447 |ATIONAL PROVIDER IDENTI NPD ‘The primary purpose of the NPI isto uniquely identify health care providers as “health care providers” in HIPAA standard transactions. ‘The NPI will replace all other identifiers assigned to health care providers, such as those assigned by health plans, goverment programs and health care purchasers for purposes of conducting these business transactions, Under the final HIPAA NPI Rule, all individual and organization covered providers will be required to obtain an NPI by May 23, 2007. {In order for your license to be renewed you must take one of the following actions: 7 stion.1: Supply the Board of Registration in Medicine with your valid NPI. You can apply Foran NPI directly by using the NPPES web site at www NPPES.cms hhs gov, Option 2: Cenity you have personally applied for your NPI and you have notre yet, Once you have received your NPI Number, ‘You rust notify the Board, Pease compete the NPI form atthe Board's web sit at wnrw massmedboard og. fi Option 3; Certify another authorized institution has applied for an NPI on your behalf and you have not received it yet (Supply instiniton's name). Once you have received your NPI Number, you must natify the Board by completing the NPI frm atthe Board's website (see Option 2) prion 4: Authorize the Board of Registration in Medicine to apply for an NPI on your behalf Option 5: f'your license status is INACTIVE. you may elect not to obtain an NPI number. Chiectsshe appropriate box below: supply appropriete information. and sign the bottom ofthe pave. My cnentNetiss PSII ola aL 1 {have personally applied fran NPI. (You mos: provide your NPI number tothe Board when received) 11 Ihave applied for an NPI using e third party enter name), (follow iniruetions for Option 3) 1D By checking this option and signing tne boom of his page, 1 Neeby authorize the Board to epply for an NPI on my bebal. © As an inactive physician, I do not wish to obtain an NPL HIPAA TAXONOMY CODES Please provide the HIPAA taxonomy (specialty) codes (refer to enclosed Taxonomy Code List). In eddition to providing the taxonomy code, please indicate your specialty in the space provided (Taxonomy Description), The primary provider taxonomy code is required if you authorize BORIM to apply for an NPI on your behalf. ‘Taxonomy (Specialy) Code ‘Taxonomy Description Print) Primary Provider Taxonomy: PIRI __ovsietrics aud cynevology Prove Tony. oocooooocdo Provider Taxonomy: CODOOOLH ‘NELREQUIRED INFORMATION In an ongoing efor 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. ‘oval Security Number: Siete of Binh (US): New Yorle Country of ith (ifouside the US): Gender: 1) Male Bi Female {for Falsifving Information on the Nat 18 US.C. 1001 authorizes criminal penelties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fect, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the samme to contain any false, fictitious or fraudulent statement or entry, Individua) offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(A) also authorizes fines of up to twice the gross gain derived by the offender if itis greater than the amount specifically authorized by the sentencing statute. tion for NPI Dissemi Cheek one box: TK authorize [to not authorize the Board of Reglstration in Medicine to provide my NPI number to any Sthoriacd hospi health plan, or healt organization. lease sign and date to confirm that all ofthe information on this form is true and accurate. Signature: Baku, Quguat wr pac: 2) 2) OFMassachusetts Board of Registration in Medicine Ss 7a 560 Harrison Avenue, Suite G-4 (JECEIWE 1 Boston, MA 02118 e 617-654-9810 4 FEB 06 2007 snmassmedboard.org [BY Dr. Betsy $ August 01/31/2007 400 Highland Ave Salem, MA 01970 Dear Colleague: ‘As you may know, the Health Insurance Portability and Accountability Act (HIPAA) mandates the use of the ‘National Practitioner Identifier (NPI), a unique identifier for health care providers, The NPI program is overseen by the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services. Under the final HIPAA NPI rule, all individual and organization covered providers will be required to obtain a NPI by May 23, 2007. Without this number, you may be ineligible for reimbursement from federally-funded benefits Programs. As a condition for renewal of your license, you must complete the NPI form on the attached page. ‘The Massachusetts Board of Registration in Medicine (Board) is assisting physicians to obtain their NPI numbers. In addition to providing this service for physicians, the Board is the designated repository for electronic storage and dissemination of the NPI number. By having your NPI in this central repository, we hope to reduce the amount of administrative duplication in your office. H instructions on the NPI fe of this letter. If you already have a NPI number, you ‘must enter it in the space provided. If you have not yet submitted an application for a NP] number. you may request that the Board apply for the NPI number on yout behalf, or you must indicate that it is being requested by another ‘entity. You must check one of the boxes regarding NPI and you must sign and date the form to authorize the Board to provide the NPE number to authorized entities, although this is not required. Should you need any assistance in ‘completing the NPI form. please contact the NPI coordinator et (617) 654-9810, {1 would also like to take this opportunity to thank you for your continued service to the citizens of the ‘Commonwealth. Sincerely, SAK a0 Martin C. Crane, M.D. Board Chair PLEASE COMPLETE NPI FORM ON THE BACK OF THIS LETTER AND RETURN TO THE BOARD IN THE GREEN ENVELOPE. PLEASE REMEMBER TO SIGN AND DATE THE FORM BEFORE MAILING. THANK YOUMassachusetts Physician Renewal Application Ri Pysetan Nome: Betsy § August, M.D. License Now 59447 PARTA 1) Current Stats: Active Renewal Due Date: 04/21/2007 Birth Date: Ifyou want to change your current status, please check one of the following boxes to indicate your nw status: Check only one: (See Renewal Instructions, page 3.) Active: O Retiring D inactive 1 Do not wish to renew 2) Addresses & Contact Information. Please confirm your addresses and make changes, fwecessary. You are required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and Business a "ANNOT . sddresses CANNOT be a Post Otice Box. Please make corrections (print) 2a) MAILING ADDRESS 400 Highland Ave : ils 2 $$ tigquiano ave a RECEIVED Mailing Address: S$ qu fore Ciyrtowm: _ SA lenr state: MO NAR 19 7 Zip:_O1470 county: USA chet cae toate, cana oad of Regist baa Eatieatentitiae in Medicine Home Address: CiyrTowm, suate: 2 County: oa Home Telephone: (__)__ Check hereto change hs adress “Home address cannot be a Post Office Box 2c) BUSINESS ADDRESS Business Address SS thawlaud Ave 400 Highland Avenue, : Leu Cityrtown:_SAlewn State: HOW Salem, MA 01970 Zip: OVA FO county: OS 4 Phone: (978)741-3700 Business Telephone! (__.. {Gf Crect ere to change ti oases: Business address cannot be a Post Office Box ‘Correct your E-mail and Fax Number below: 3) E-mail Address: 4)Fax Number: _978-741-3354 3 Spesais (See Renew Istana, page 4) Daiwa? | is Adonal Speciation ‘Obseries and Gynecology o_ | ol al | ‘6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Astociation (AOA) Information. (Gee enclased instructions and Renewal Instructions, page 4.) ‘List Certifying Board(s) below: Update General Certificates and Subspecialty Certificates below. Please add additional Certifications as required. Board Name ABMS.or AOA| Certifieate/Subspecialty Datete? ‘Obstetrics & Gynecology ABMS _ | Obstetrics and Gynecology o Page 1 of 9Massachusetts Physician Renewal Application Piiysiclan Name: Betsy $ August, M.D. License No 59447 ‘(See Renewal Instructions, page 4) 7) Drug License Numbers Corrections: 1) Massachusetts: ») Federal (DEA): ©) Federal (DEA) XS: Please make corrections as necessary 8) Other states where you are now licensed to practice 10) List all work sites in Massachusetts, including health care facilities (where you are credentialed), private offices, clinics, nursing homes, ete, For the names of the health care facilities, refer to Reference Table 4 on page 18 of the Renewal Instraction booklet. Include any affiliations with Internet-based prescribing services ‘or companies. Please provide all information on all work sites, attaching a separate sheet, if necessary. [List the names ofall work sites in Massachascits Location Gee above and description on page 4) (City oF Town) Massachusetis General Hospital ‘North Shore Medical Center - Salem Hospital ‘State 11) Care of patients in Massachusetts (See Renewal Instructions, page 4.) ‘Average weekly hours involved in: a) inpatient care _20__ sik b) outpatient care 60 hursiwh Change to: 12) Medical Li lity Insurance Information (See Renewal Instructions, page 5,) ‘Check one. Locum tenens must list policy dates. My medical liability insurance is provided through: Ci insurance Carrier (complete beiow) ‘Curent Insurance Cartier: CRICO Poley dates: From 14/9) To i307 ‘Type ofPolicy: (I Claims made with waitcoverage JEL Occurence Policy (Enclose a copy ofthe certificate of insurance o the face sheet) Change to: 1 Letter of Credit subject to Board approval (Artech @ copy.) OD tam registers with Active status but I am not required to have medical liability insurance because I am: Check one: [Not involved with direct or indirect patient care in Massachusetts DD AGovernment Employee under Federal Tort Claims Act (FTCA) C1 Otherwise exempt (Please explain) 13) Do you perform any surgery in your Massachusetts office? (See Renewal Insirucions, page 5.) If Yes, please complete Form PCA-O "Office Based Surgery” Form on page 8. Yes No Page 2 of 9Massachusetts Physician Renewal Application License No: $9447 hysician Name: Betsy S August, M.D. In questions 14-21, the phrase "time period" refers to the following — all time from the day you signed your license Renewal Application to the day you sign this Renewal Application, (See Renewal Insiructions, page 5.) ‘You must check either YES or NO to each question, Provide details on Farm R if you enswer "YES" to any questions. Refer to Renewal Instructions for additional information and definitions ee 14) CLAIMS MADE 8) 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 sgainst you during this time period? (see above. b) PENDING: Are there any unresolved malpractice claims against you today, ic., any claims that have not been finally settied or finally adjudicated? 15) CLAIMS CLOSED ‘Has any medical malpractice claim against you (whether or not 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. 4) New: Have there been any claims, other than medical malpractice claims, filed against you during this time period? 1) Resolved Have you resolved, seed o adjudicated any lawsuits other than medial malpractice claims, during this time period? 17) CRIMINAL CHARGES. 1) Have you been charged with any criminal offense during this time period? +) Have any criminal offenses/charges against you been resolved during this time period”? ©) Are there any criminal charges pending against you today? 4) Are any Applications for Issuance of Process pending against you? 18) INVESTIGATIONS AND DISCIPLINARY ACTIONS 2) Have you withdrawn an spplication 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 of an investigation by any governmental authority, health care facility, group practice, employer or professional association? 6) Have you been the subject ofa disciplinary action taken by any governmental authority, healthcare facility, group practice, employer or professional association? 19) Have your privileges 10 possess, dispense or prescribe controlied substances been suspended, revoked, Genie’, 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, erminated, imposed a surcharge or ‘co-payment, or placed any condition releted 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 lability insurance carrier? 723) CME CERTIFICATION: 1) Have you completed your CME requirements preceding your renewal dae? (Ves (1 No 1) no, are you requesting & CME wave? Yes gino [ACCME waiver request form must be submitted at leat 30 days prior to your eens expiration date ¢) If you are exempt from CME requirements, check reason for exemption. (See Renewal Instructions, page 8.) (CME EXEMPTION: (check one) [1 Inactive Status 2 Residency/Fellowship training Page 3of9Massachusetts Physician Renewal Application a Physician Name: Betsy S August, M.D. License Now: 59447 FARTC 8 ‘Check One: PHYSICIAN PROFILE i J have reviewed my Physician Profile ot hip/profles.massmedboard.org and confirm thatthe information is accurate, (Please note thet if you changed or corrected your business address, business phone number, practice specialty, board cerifcation and/or hospital affiliations on your renewal application, your Physician Profile will also be updated) have reviewed my Physician Profile and sttached a copy of the Profile with corrections. My status is Inactive and I do not have « Physician Profile. (See Renewal Instructions, page 11.) CERTIFICATIONS 1) certify that I have complied with my obligations to report abuse or neglect of children pursuant to GL. ¢. 119, se. 51A, and] understand the punishment for failure to comply. a oo A 2) certify that have complied with my obligations to report abuse or neglect of disabled persons pursuant to G-L. c. 19C, sec. 10, and understand the punishment for failure to comply. 3) Leortify that have complied with my obligations to report abuse, neglect of financial exploitation of elderly persons pursuent to G.L. €.19A, see, 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 G.L. ¢. 112, sec. 12A, 5) I certify that I have complied with my obligations to report the treatment of vietims of rape or sexual assault pursuant to G.L. 112, sec. 12A 172. {6 certify 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) I certify that I have complied with 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. c. 112, see. 2. 8) I certify that I have complied with my obligations to file Massachusetts tax returns and to pay Massachusetis taxes, and 1 understand ‘tha, pursuant to G.L. c. 62C, see. 49A, my license shall not be issued or renewed unless I make these certifications under penalties of perjury. 9) | ceify that Ihave complied with my obligation related 1 the reporting of employees and contractors pursuant to G.L. 62E. 10) certify that Ihave complied with my obligations elated tothe withholding and remitng of child suppor pursuant to G.L. 1194. 1 cesify that have complied with my obligations to fle an Incident Report with the Board when certain adverse events occur in my private office, pursuant to G.L. c. 112 sec. 5 and the Patient Care Assessment Regulations, 243 CM R. 3.00 et sea. understand tht the Patient Care Assessment (PCA) programs at the heelth care facilities where I practice report certain Major Incidents to the Board. 12) certify that I have complied with my obligations to disclose my ownership interest in any partnership, corporation, firm or other legal entity to which I have referred a patient for physicel therapy services pursuant to G.L. c. 112, ec. I2AA. 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. seme BAM QW one FLY OF 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 @Massachusetts Board of Registration in Medicine 560 Harrison Avenue, Suite G-4 Boston, MA 02118 617-654-9810 ‘worw.massmedboard.org, Dear Colleague: As you may know, the Health Insurance Portability and Accountability Act (HIPAA) mandates the ‘use of the National Practitioner Identifier (NPI, a unique identifier for health care providers. The NPI program is overseen by the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services. Under the final HIPAA NPI ule, all individual and organization covered providers will be required to obtain a NPI by May 23. 2007. Without this number, you may be ineligible for reimbursement from federally-funded benefits programs. Asa condition for renewal of your license, you must complete the NPI form on the attached page. The Massachusetts Board of Registration in Medicine (Board) is assisting physicians to obtain their NPI numbers. Jn addition to providing this service for physicians, the Board is the designated repository for electronic storage and dissemination of the NPI number. By having your NPI in this, central repository, we hope to reduce the amount of administrative duplication in your office Please follow the instructions on the NPI form. If you already have a NPI number, you may enter the space provided. If you have not yet submitted an application for a NPI number, you may request that the Board apply for the NPI number on your behalf. You must sign and date the NPI form to authorize the Board to provide the NPI to authorized entities, Should you need any assistance in completing the NPI form, please contact the NPI coordinator at (617) 654-9810. | would also like to take this opportunity to thank you for your continued service to the citizens of the ‘Commonwealth, Sincerely, SAK 0 ‘Martin C. Crane, M.D. Board Chair Please complete the NPI form on the following page. Page 6 of 9 th oh aMassachusetts Physician Renewal Application 1m Name: Betsy $ August, M.D. License No 59447 NATIONAL PROVIDER IDENTIFIER (NPD. ‘The primary purpose ofthe NPI isto uniquely identify health care providers as “healthcare providers” in HIPAA standard transactions} ‘The NPI will replace all other identifiers assigned to healthcare providers, such as those assigned by healt plans, govemmert program, and healthcare purchasers for purposes of conducting these business transactions. Under the final HIPAA NPI Rule al individual and organization covered providers will be requi In order for your license to be renewed you must take one of the following actir Qntion 1: Supply the Board of Registration in Medicine with your valid NPI. You can apply for an NPI directly by using the NPPES web sive at ww, NPPES.cms hhs gov 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 complete the NPI form at the Board's web site at www.massmedboard.org. Option 3: Certify another authorized institution has applied for an NPI on your behalf and you have not received it yet (supply institution's name). Once you have received your NPI Number, you must notify the Board by competing the NPI form atthe Boards website (See Option 2). Option 4; Authorize the Board of Registration in Medicine to apply for an NPI on your behalf. Option $: IF your license status is INACTIVE, you may elect not to obiain an NPI number. Check the appropriate box below, supply appropriate information, and sign the bortom of the page. Byers (PMMA Ihave personally appiedforan NPI. (You must provide your NPI number to the Board when ecsive.) 1 Ihave appied for an NPI using third party (enter name): (follow instructions for Option 3) 1D By checking this option an signing the bottom ofthis page, I hereby auhorize the Board to apply for an NPI on my behalf OAs an inactive physician, | do not wish to obtain an NPI. HIPAA TAXONOMY CODES Please provide the HIPAA taxonomy (specialty) codes (refer to Renewal Instructions, page 21 for more information). In addition 10 providing the taxonomy code, please indicate your specialty in the space provided (Taxonomy Deseription). The primary provider taxonomy code is required if you authorize BORIM to apply for an NPI on your behalf. 1d to obtain an NPI by May 23, 2007. ‘Taxonomy (Specialty) Code ‘Taxonomy Description (Print) Primary Provider Taxonomy: fe] VI) [el [ol [ol [ex —eeatetnis aud Ayuccalagy Provider Taxonomy: ooo LO Provider Taxonomy: 0005 CO NPLREQUIRED INFORMATION In an ongoing effort to improve the quality ofthe information we collect, 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): vs ‘Country of Birth (if outside the US): Gender: O Mate Female mation on the Nation i ication 18 USC. 1001 authorize criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully flsifes conceals or cover up by any wick, scheme or device a material ft, or makes any false, fettios or faudulent statements or representations, oF makes any false writing or document knowing the same to contain any false, fettious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of upto $500,000. 18 U.S.C. 35714) also authorizes fines of upto rwce the rosé gain by the offender if is greater than the amount specifically authorized by the sentencing stat. the Bosrd of Registration in Medicine to provide my NPI number toany authorized hespital, health plan, or health organization. Please sign and date to confirm that all of the information on this form is true and accurate. signamre:__ PAG, Bognor Date: _3 14 {7 Page 7 of 92/80 S Commonwealth of Massachusetts 8 Board of Registration in Medicine & Ten West Street a Boston, Massachusetts 02111 a ‘ALEXANDER F. FLEMING (617) 727-3086 © atonasaaten ‘a Agency win Exact Of ol Coneune take an Bunioes Rgieson June 3, 1993 Betey S. Au REDACTED Copy Salem Women’s Health Associates 331 Highland Avenue Salem, Massachusetts 01970 Re: Docket No, 93-104 Dear Dr. August? 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 thie matter, The Committee appreciates the time and effort which you expended in preparing your response. If you have any questions, please feel to call me at 617-727-1788, ext. 310 or write to the above address. Very truly yours, fl Mon Peter Clark Director of EnforcementSS Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street Boston, Massachusetts 02114 8 8 3 8 Q 8 est peanoen sana (617) 727-3086 ‘An Agency within the Exeeutive fos of Coneumer Aare and Business Roguation dune 3, 1993 Re: Betsy 8. August, M.D. Docket No, 93-104 Dear ‘The Complaint Committees of the Board carefully considered the information you have furnished us regarding your complaint against the physician referenced above, A copy of your complaint was sent to the physician, who wa: aired to respond in writing to the Board regarding the jesues you raised. After a thorough review of this evidence, the Committee determined that your complaint and the physician’s response should be placed in the permanent record of the physician. While the Committee declined to recommend the initiation of formal disciplinary action in this case, it is appreciative of your actions in bringing thia matter to its attention. Should you have any questions or additional material which you wish the Board to consider, please write to the Docket Administrator at the above address. 1 regret that the Board does not have sufficient staff to respond to telephone inquiries regarding complaints. Very truly yours, Ve Peter Clark Director of EnforcementCommonweaith of Massachusetts Board of Registration in Medicine Ten West Street Boston, Massachusetts 02111 8 8 8 (617) 727-3086 ae sate ont ntti teach April 1, 1993 Betsy 8, August, M.D. Re: Complaint No. 93-104 Dear Dr, August: ‘The Board of Registration in Medicine has received a complaint regarding your conduct, in the practice of medicine, a copy of Which is enclosed. The Board is obligated by law to investigate such matters relating to the proper practice of medicine, In compliance with thie mandate, the Board's Complaint Connittes has directed the staff of the Board to gather information on all such complaints : Please provide a written response to the issues raised dn 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. Plense be aGvised that Board Regulation 243 CMR 2.07 (22) requires that you respond within thirty 4 receipt of this letter. Your response should bi Docket Administrator, Disciplinary Unit address. After your response is received, the case will 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 aa to the disposition of this complaint. Thank you for your attention to this matter. Very truly yours, Leap ei foasfe. ‘Mat McGonagle Docket Administrator EnclosureBimonwoaith of MaseM@husetts Board of Registration in Medicine Ten West Street Boston, Massachusetts 02111 (617) 727-3086 ‘An ancy witha a ExacstveOftca of Conmumer Aer and Businoes Reguttion April 1, 1993 Ret Betsy S. August, M.D. dnt No. 93-104 Dear Your complaint regarding the physician named above has been received. The physician involved has been asked to respond in writing to your complaint. Any future correspondence regarding your complaint should include the name of the physician and the complaint number as it appears in this letter. If you wish to bring additional information bearing on QUE complaint to the attention of the Board, please furnish in writing to the Complaint Departnent at'the address above. “Be sure to include the physician's name and the complaint number on all correspondence. Yours very truly LEG ELA Docket Administrator SS e0-ez/20' 19kSalem Wumen’s Health Assoc. ates etsy August M.D., F.A.C.O.G. # Luisa Kontoules M.D, F.A.CO.G, ¢ Stepheit Pouchtk M.D, FACOG, "331 Highland Avenue ¢ Salem, Massachusetts 01970 + S08 741-3700 January 11, 1993 Daniel 8, Bilis, H.D. Massachusetts Medical Society 1460 Main, Street Walthan, MA 02154-1649 Dear Dr. ELI ‘Thie letter te in response to the complaint brought by The firac ‘The patient bringe up several issues vhich I will addres iague vas elain that her problem las been of short duration. In reality, her problen has been longatanding since 1990. She was seen by at his former office for irregular bleedinj 4 y In addition, her blood pressure Inbiie. 1 did not rk from hie previous exane, She saw lim in thie office 8/14/91, again with irregular Bleeding. Her firet visit with ne for this problem was on 9/30/92. On that day, she did not have hot flashes, vaginal dryneou, nor irritability. K exemined her and did her annuel checkup. I discussed the Literature that our nures had sent her on 9/3/92 concerning the menopause, I explained that although I was questioning the menopause, there vare other reasons for awenorrlies to evaluate. I alaye ack patients if they have any questions, Metpath Je the lab which drava blood in our office, They do not pay ua rent, wor do we get any profits from lab vork dravn. They are a part of our office solely as a convenience to our patients. Patients save tine and frustration by not baving.to travel to Saleu Hospital for their labvork, Metpath offers a discounted rate to patients who do not have insurance nor noney, The can aloo arrange to pay what they can ons scheduled basis. Patients can ask for help when needed, Metpath also offere a discounted "package" for bloodwork drawn for profiles such as pregnancy and amenorrhea. ‘The cost 4a less than the individual ttens alone. My evaluation included FSH, lil, estradiol, prolactin, and a thyrofd panel. I considered adrenal function due to fluctuations in blood pressure, body habitue and hair pattern. 4o a very verbal, intelligent woman. At any time throughout her \dical care he was able to ask for tha rationale behind her workup as well ao tate her financial needs, Our office makes every attempt to be of service to our patients, If she did not ask for more information, it was not because sue was not given the opportunity, ‘Thank you. Sincerely, | Bib toguch a Betey August, 4.D. BA/SbDecember 14, 1992 Division of Insurance Office of Consumer Affairs 280 Friend Street ‘Boston, MA 02114 Dear Sir or Madam: On September 30, 1992, I went to Dr. Betsy August, Women's Health Associates, Highland Avenue, Salem, MA, for my annual check-up, Iam 49 years old and for the past two years have experienced a gradual cessation of my menstrual cycle, which at my ago fs perfectly normal. I asked Dr. August ifT could stop using birth control, and ‘she said that she would need to check my estrogen level in order 10 make that determination. She lead me to the front of her office where someone drew my blood, I assumed it was cone of her nurses, Well, to make a long story short, she ordered a battery of tests, ‘which amounted to $782.50. (A copy of the lab bill is enclosed,) Please refer to the enclosed letter to MetPath for the ensuing events. In response to that letter, a copy of which was sent to Dr. August, she called me and left a message on my answering ‘aching telling me that the estrogen test was necessary. I was cestainly not questioning ‘with that test, it was the other ten or eleven, Ihave recently come to learn that 2 person from MetPath did in fact draw my blood, for that person is housed at Dr. August's office, Zsn't that convenient? I want to know why these all tests were ordered. Very truly yours, ce: Mr, Robert Ward ‘Massachusetts Medical Society 1440 Main Street ‘Waltham, MA 02154 88 80/22/80 earCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Betsy S August, M.D. License No. Physician Name: Current Status: Active License Expiration Dat 4) Activity Status: Active 2) Address & Contact Information Mailing Address: §5 Highland Ave Suite 103, Salem Massachusetts - 01970 United States of America Business Address: 85 Highland Avenue Suite 103 Salem Massachusetts - 01970 United States of America (G78) 741-2500 3) Email Address: 4) Fax Number: (978) 741-1146 5) Specialties Obstetrics and Gynecology 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMS/AOA Board Name Gertitcation ‘Subspeciaity ABMS Obstetrics & Gynecology Obsteties and Gynecology 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice New Hampshire 9) States where you were previously licensed None kopoted Nore Previous 10) Work Sites List of all work sites in Massachusetts, including health care teciltes (where you are credentialed), private office, clinics, nursing homes, etc Worksite Location North Shore Medical Center - Salem Hospital Paget of 5 Dato: sara014 Time: 6:56 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.D. License No.: 59447 11) Care of patients in Massachusetts ‘Average weekly hours involved in: a) inpatient care 20 hrsMvk b) outpatient care 60 hrsivk 12) Medical Liability insurance Information Insurance Carrier Policy Start Date Policy End Date —_Policy Type Promutual insurance 142108/2010 1208/2011 ‘Occurrence Policy 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made 1a) New: Have you received notfication of a ciaim, 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: Are there ary unresolved malpractice claims against you today, 1., 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 this ime period? 16) Other Civil Lawsuits ‘Question 16 refers to cleims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. a) New Have there been any clams, other than mecial malpractice claims, fled agalnst you duting ths ime perio by Resolved. Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during this period? 47) Criminal Charges 8) Have you beer charged wit any erminal offense during this period? } Have any criminal offenses/charges against you been resolved during this time period? ©) Are there any criminal charges pending against you tocay? ) Are any Application of Issuance of Process pending against you? 18) Other Issues. )Have you withdrawn an application to ary governmental authority, health care facility, group practice employer or professional association”? ip Hale you evr taker leave of absence om ary heath care facity, foup practice or epayer? c) Have you been the subject of an investigation by any governmental authonty, health care facility, group practice, employer or professional association? ¢) Have youbeen the subject of a discpinary ection taken by any governmertal authority, health care Tacilly, 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? 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 ot 5 ate: sarz011| “Time: 6:56 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.O. 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 Gategory 1 and 89 hours in Gateyory 2) for this Yes renewal period? (Ifyou are in an approved Residency! Fellowship program, or i your are renewing your license for the fist time, please answer Yes) Page sot5. Date: 51412091 Time: 6:56 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application ian Name: Betsy S August, M.D. License No.: 59447 Physi 23) Do you have a medical condition that interferes in any way or limits your ability to practice medicine? 24) Have you used any chemical substance(s) which in any way interferes with your ability to practice medicine? Pege 4 of 5 Time: 8:56 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.D. License No.; 59447 Compliance with Legal Responsibilities Online profile: [Xj have reviewed my Physician Profile and confirm that the information is accurate. 41) understand and agree to comply with my obligations to report abuse or neglect of children pursuant to M.GL ¢. 119 sec. 51 and | understand the punishment for failure to com 2) | understand and agree to comply with my abigations io report abuse of neglect of ésabied persons pursuant to M.G.L-¢. 19C sec. 10 and | understand the punishment for failure to comply. 3) | understand and agree to comply with my obligations to report abuse, neglect or Financial exploitation of elderly persons pursuant to M.G.L.c. 19A sec. 76 anc | understand the punishment for failure to comply. 4) ‘understand and agree to comply with my obligations to report the treatment of wounds, burns and other Injures pursuant to M.G.L. ¢. 112 sec. 12A and understand the punishment for failure to comply. 6) | understand anc agree o comply with my obigatons to repo the treatment of vats of rape or sexual ‘assault pursuant to M;G.L ¢. 112 sec, 124 1/2 and | understand the punishment for fallure to comply 6) | understand ang agree to comply with my obligations to report a physician to the Board of Medicine pursuant to M-G.Lc. 112 sec. 5F, when ihave a reasonable basis f0 believe that a person violated any Provisions of M{GL.c 112 sec 5'or any Board reguiation. | understand and agree to comply with my obkgations related to charging and collecting fees from Medicare 7) ‘eneicares in accordance wih ine Medcare ee schede pursuant to M GL 0112800 2 8) | understand and have complied with my obligations to fle Massachusetts tax returns and to pay Massachusetts taxes and | understand that, pursuant to M G.L. c. 62C sec. 484, my license shall not be Issued or renewed unless I make this certification under penalties of perjury. 8) understand anc agree to comply with my obligations related to the eporting ofthe wages of employees and contractors pursuant to M.G.L.o. 626 Sec. 2. 10)1 understand and agree to comply with my obligations related to the withholding and remitting of child ‘support payments pursuant to M.G.L. c. 1198. 11)/ understand and agree to comply with my obligations to file an Incident Report with the Board when certain averse events accu n ry private office, pusuantio MG c 112 sec 8 and 243 CMR 3.00 et seq and | understand that the Patient Care Assessment (PCA) programs at the health care facilties where | practice report certain Major incidents to the Board. 412)| understand and agree to comply with my obligations to disclose ownership interest in any partnership, ‘corporation, firm or other legal entity to which rhave referred a patient for physical therapy services, Pursuant to MG c. 112 sec. 120A, 18)! am aware of my obligations and responsibilities under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), including the requiremert that | obtain and provide to the Bosrd a National Provider Identiner (NP) number 414)/ understand and am in compliance with HIPAA end all other federal and state obigations placed upon me ‘as a physician. 15)| understand that as an applicant for license renewal to practice medicine @ eriminel record check may be ‘conducted for conviction and pending criminal case information only from the Criminal History Systems, Board and thet it will not necessenty disqualify me Ihave reviewed the above statements and certify that | understand my requirement to comply with esponsibilities and obligations of each and agree to do so. [Under penaities of perjury, | declare that | have examined this renewal application and all of its accompanying instructions, forms and statements, and to the best of my knowledge and belief, | Certify that the Information contained herein Is true, accurate, and complete. Page $ of 5 Dato: smar20t4 Time: 8:56 ANCommonwealth of Massachusetts te) Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.O. ‘Current Status: Active License Expiration Date: 6/19/2013 41) Activity Status: Active 2) Address & Contact information Malling Address: 96 Highland Ave ai Sate 08 lem Maseachusetts-01970 United States of America Home Address: Business Address: 55 Highland Avenue Suite 103 Salem Massachusetts - 01970 United States of America (678) 741-2600 3) Email Address: 4) Fax Number: (978) 741-1146 5) Specialties tetrics and Gynecology 68) Current American Board of Medical Specialties (ABMS) or American Osteopathle Association (ACA) formation ABMSIAOA Board Name Certification ‘Subspeciaty 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 New Hampshire 9) ‘States where you were previously licensed None Reported 10) Work Sites st ofall work sites in Massachusetts, including health care faciltes (where you are credentialed), private office, clinics, nursing homes, etc Worksite Location North Shore Mecical Center - Salem Hospital Paget of § Date: st4r2013 Time: 6:06 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Applicat Physician Name: Betsy S August, MO. License No.: 59447 11) Gare of patients in Massachusetts Average weekty hours involved In: 9} inpatient care 20 tat ) outpatient care 40 hrs/wk 12) Medical Liability Insurance Information Insurance Carrier Policy Start Date Policy End Date —_Policy Type. Coverys saniarot2 1anido13 Occurrence Potioy 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made a) New. Have you rece'ved notification of a claim, whether or not a lawsuit was filed on that claim, or has 20 mecical malpractice claim been made against you during this me period? ») Pending: Are there ery urvesoived malpractice clams against you today, ¢, ary clas that have not been resolved, settled or adjudicated during this time period? 18) 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 this time period? 16) Other Civil Lawsuits ‘Question 16 refers fo claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 28) New Have here been any claims, other than medical malpractice aims, lec against you curing this me perio b) Resolved Have you resolved, settled or adjuvicated any lawsuits, other than medical malpractice aims, during this period? 17) Criminal Charges 2) Have you been charged with any criminal offense during this period? b) Have ary criminal offenses/charges against you been resolved during this time period? ©} Ate there any criminal charges pending against you today? ) Ave any Application of Issuance of Process pending against you? 48) Other Issues a) Have you withdrawn an application to any governmental authority, health care facility, group practice employer or professional association? Have you ever taken a leave of absence from any health care facity, group practice or employer? . ny, 2} Hive You sen the subject ofan investgaton by any governmental uhorty, including the Maseacrusetts Board of Regstation in Medicine or any other state medical board, nealth care factity, oun practice, employer oF professional association? ) Have you been tne subject ofa displinary ation taken by any governmental authoriy, health care facity group practice, employer or professional association? 48) Have your privileges to possess, dispense or prescribe controlled substances been suspended, » FevoKea, dented, restricted by or surfendered 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 response to an inguiry by a medical liability insurance carrier? Page 2 of 5 Date: 4472013 “Time: 6:06 PH‘Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.D. License No.: 59447 22) Have you completed all CPD requirements (100 hours of CPD of which 10 hours must be in risk management, Requirement: 40 hours creditin Category 1 and So hours in Category 2)for this Yes fenewal period? (f you are in an approved Residency! Fellowship program, or f your are renewing your license for the first time, please answer Yes) Pages ot5, Dete: 14/2013, Time: 6:06 PM.Commonwealth of Massachusetts ww) Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.D. License No.: 59447 23) Do you have a medical condition that interferes in any way or limits your ability to practice medicine? au Hv ma any chen substan) nh nay vay note th ours npn ant ss) oen many ay your eity Paged of 5 Date: 24472013 ‘Time: 6:06 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, MD. License No.: 59447 ‘Compliance with Legal Responsibi Online profil [i]! have reviewed my Physician Profile and confirm that the information is accurate, 4) ‘understand and agree to comply with my obligations to report abuse of negiect of children pursuant to M.GL. © 119 sec. 514 and | understand the punishment for failure to comply 2) | understand and agree to comply with my obligations te report abuse or neglect of disabled persons: pursuant io MGL c. 19C sec. 10 and I Understand the punsshment for failure to comply, 3) understand and agree to comply with my obligations to report abuse, neglect or Financial exploitation of elderly persons pursuant to MG. c. 19A sec 16 and | understand the punishment for failure to comply. 4) | understand anc agree to comply with my obligations to report the treatment of wounds, burs and other injuries pursuant fo MG.L ¢. 112 sec. 124 and | understand the punishment tor fallure to comply. 6) Juncerstend and agree to comply with ry obigatons to report he treaiment of vn of rape of sexta assault pursuant to M.G.L. ¢. 112 sec. 12A 1/2.and | understand the punishment for failure to comply, 6) | understand and agree to comply with my obligations to report a physician to the Board of Medicine pursuant fo M.G.L-€. 112 sec, 5, when Ihave a reasonable basis to believe thal a person violated any provisions of MGL.c 112 sec. 5'or any Board regulation, 7) | understand anc agree to compy with my oblgatione related to charaing ag collecung fees from Medeare beneficiaries in accordance with the Medicare Tee schedule, pursuant to MG.L c. 112 sec. 2 8) | understand and have complied with my obligations to fie Massachusetts tax returns and to pay Massachusetts taxes and | understand that, pursuant to MG. ¢. 62C sec. 49A, my license shall not be issued or renewed unless | make this certification under penalties of perjury. 9) | understand and agree to comply with my obligations related to the reporting of the wages of employees ‘and contractors pursuant to M.G.L. ¢. 62E See. 2 10)] understand and agree to comply with my obligations related to the withholding and rernitting of child ‘support payments pursuant to M.G.L. ¢. 119A 11)] understand and agree to comply with my obligations to file an Incident Report with the Board when certain ‘adverse events occur in my private office, pursuant to M.G.Lc. 112 see, 5 and 243 CMR 3.00 el seq, and | Understand that the Patient Care Assessiment (PCA) programs at the health care faciities where I practice report certain Major Incidents to the Board. 442) understand and agree to comply with my obligations to disclose ownership interest in ary partnership, ‘corporation, fmm or other legal entity to which Ihave referred a patient for physical therapy services, pursuant to'M.G.L¢, 112 see. 1: 13)| ar aware of my obligations and responsibites under tne Health Inuronce Portability and Accountabity al of 1896 (HIPAA), cluding the requrement hat obtain and provide tothe Board & National Prowder Identifier (NPI) number. 14)] understand and am in compliance with HIPAA and all other federal and state obligations placed upon me ‘es a physician 16)! understand thal as an applicant for a license renewal to practice medicine @ criminal record check may be ‘Conducted for conviction and pending criminal case information only from the Criminal History Systems. Board and that it will not necessarily Gisqualify me. X] Ihave reviewed the above statements and certify that | understand my requirement to comply with Bl ij tesponciillies and obligations of each and agree to Wo so. Under penalties of perjury, | declare that | have examined this renewal application and all of its accompanying instructions, forms and statements, and tothe best of my knowledge and belle, | Certify that the information Contained herein is true, accurate, and complete. Pege 5 of 5 Date: 51472013, ‘Time: 6:96 PALa Massachusetts Physician Renewal Application Phin Name ely S Angus M.D. Lemna: sur Derr PARTA 1) Current Status: Active Renewal Due Date: 04/21/2009 Birth Date: If you want to change your current status, please check one of the following boxes to indicate your new status: Check only one: (See Renewal Instructions, page 3.) 1 Active 1 Retising 1D Innctive Do not wish o renew 2) Addresses & Contact Information. Pleate confirm your addresses and make changes, if necessary. You are required to notify the Board of Registration in Medjetie within 30 days of any change of address. Home and Business addresses CANNOT be » Post Office Box. Rare 22) MAILING ADDRESS. elie - a SummMaoT 7 o®, sing ato 5 ghia ip Gud 4, 3°] ciyrtoun: ALC, sate: 14 & & oey Sy | Zin: 01970 __ Country: 1 Oetteremctarcemsasies \ igh oN ————— 2b) HOME ADDRESS: oe Poo won) ——— 1D Check here chenge ois adress Home adéress cannot be a Past Office Box Bre eons AION, (55 Highland Avenue Salem, MA 01970 cinytown: GA SYM Stare: M14 Phone: (978)741-3700 1D Check here to change si oddest Business address cannot be a Post Office Box ‘Correct your E-mail and Fax Number below: 3) E-mail Address: 4) Fax Number: '5) Specialies (See Renewal Insiructons, page) Delete? | _ List Additional Specialties: Obsteuics and Gynecology a a o ‘6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Astoclation (AOA) Information. (See enclosed instructions and Renewal Insiructions, page 4.) List Certifying Board(s) below: ‘Update General Certificates and Subspecialty Certificates below. Please add additional Certifications as required. Board Name ABMS or AQA| Certificate/Subspecialty Obstetrics & Gynecology ‘ABMS _ | Obstetrics and Gynecology efolo] aff Page 1 of 7 ce By eergieo 18 BRS- _ *Massachusetts Physician Renewal Application Physician Name: Betsy § August, M.D. License No.: 59447 (See Renewal Insirctions, page 4) Please make corrections as necessary 7) Drug License Numbers Corrections: 8 Other states where you are now licensed to practice a) Massachusetts: PR eee eee teeeeee eeceeree ee ) Federal (DEA): 9) States where you were previously licensed ©) 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 companies. Please provide all information on all work sites, attaching a separate sheet, if necessary. iste names of al work aes fa Massachonels Tocatan Sete = (See above and description on page 4.) (City or Town) Massachasets General Hospital ‘North Shore Medical Center - Salem Hospital Perey & ae iE 11) Care of patients in Massachusetts (See Renewal Instructions, page 4) Average weekly hours involved in: a) inpatient care 20 hrs/wk Change to: _._ hrs/wk b) outpatient care 60 hrsiwk Change to: hhrsiwk 12) Medical Liability Insurance Information (See Renewal Instructions, page 5) ‘Check one, Locum tenens must list policy dates. My medical lability insurance is provided through: Insurance Carrier (complete befow) Current insurance Carrer: CRICO Change to: Potcy dts: From J /2/0@ to. JR/ BL Type ofPolicy: Cl Claims made with il coverage Oceutence Policy (Enclose a copy of the certificate of insurance or the face shee!) D1 Letter of Credit subject to Board approval (Aniach a copy.) C1 1am registering with Active status but I am not required to have medical Cheskon: [1 Not involved with director indirect patient cere in Massachusetts (_AGovernment Employee under Federal Tort Claims Act (FTCA) Otherwise exempt (Please explain): bility insurance because I am: 13) Do you perform any surgery in your Massachusetts office? (See Renewal Insiructions, page 5.) Yes No IF Ys, please complete Form PCA-O "Office Based Surgery” Form on page 8 Page 2 of 7 lg Paerereae Massachusetts Physician Renewal Application Physician Name: Betsy S August, M.D. License No 59447 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 5) You must check either YES or NO to each question. Provide details on Form R if you answer "YES" to any questions. Refer to ‘Renewal Instructions for additional information and definitions. YES NO 14) CLAIMS MADE, ‘8) NEW: Have you received notification of a claim, whether or not a lawsuit was filed on that claim, or hhas any medical malpractice claim been made against you during this time period? (sec above). by) PENDING: Are there any unresolved malpractice claims against you today, i¢., any claims that have ‘not been finaly setled or Ginally adjudicated? 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 this time period? 16) OTHER CIVIL LAWSUITS Question 16 refers to claims or actions relsted to your competency to practice medicine or your professional conduct in the practice of medicine. 4) New: Have there been any claims, other than medical malpractice claims, filed against you during, this time period? by Resolved: Have you resolved, setled or adjudicated any Inwsuits, other than medical malpractice claims, during this time period? 17) CRIMINAL CHARGES: 1) Have you been charged with any criminal offense during this time period? 1b) Have any criminal offenses/charges against you been resolved during this time period? ©) Are there any criminal charges pending against you today? 4) Are any Applications for Issuance of Process pending against you? [i8) INVESTIGATIONS AND DISCIPLINARY ACTIONS 1) Have you withdrawn an application to any governmental authority, health care fcility, group practice, ‘employer or professional association? 'b) Have you ever taken @ leave of absence from any health care facility, group practice or employer? ©) Have you been the subject of an investigation by any governmental authority, heath care facility, group practice, employer or professional association? ) Have you been the subject of a disciplinary action taken by any governmental authority, health care fecility, roup practice, employer or professional association? J 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, Genied, 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? Bi) Has any medical liability insurance carrer restricted, limited, terminated, imposed 2 surcharge oF ‘co-payment, of placed eny condition related to professional competency or conduct on your coverage, oF have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by ‘medical libility insurance carrier? 22) CME CERTIFICATION: 3 "> Have you completed your CME requirements preceding yourreneval dnt ee (No b) Ifo, are you requesting a CME waiver? DY¥es [No |A.CME walver request form must be submitted atleast 30 days prior to your license expiration date. ¢) Ifyou are exempt fiom CME requirements, check reason for exemption. ‘See Renewal nsiactions, page 8.) (CME EXEMPTION: (check one) Inactive Status C1. Residency/Fetlowship training Page 3 0f7 1gbegert oa“Massachusetts Physician Renewal Application Bene Physictan Name: Betsy S August, M.D. License No $9447 PART C CERTIFICATIONS s 1) I certify that I have complied with my obligations to report abuse or neglect of children pursuant to G.L. c. 119, sec. $1, and understand the punishment for failure to comply. 2) Leenify that I ave compli with ny obligations to report abuse of neglect of disabled persons pursuant 6 G.L. 190, 8 10, ay Tundersand the punishment for fur wo comply. 3) | certify that I have complied with my cbligations to report abuse, neglect or financial exploitation of elderly persons pursuant to G.L. ¢.19A, sec. 15, and I understand the punishment forfeiture to comply. 4) I certify that I have complied with my obligations to report the treatment of wounds, burns and other injuries pursuant to G.L.¢. 112, sec. 12A. 5) 1 certify that have complied with my obligations to report the treatment of victims of rape or sexual assault pursuant to GL. ¢. 112, see. 12A 12. 6) certify thet I have complied with my obligations to report a physician to the Board of Medicine, pursuant to G.L.c. 132, sec. 5F, when I have a reasonable basis to believe that person violated any provisions of G.L.¢. 112, sec. § or any Board regulation. 17 Seentfy that I have complied with my obligations related to charging and collecting fees from Medicare beneficiaries in cordance with the Medicare fee schedule, and I understand my obligations under G.L. c. 112, sec. 2 8) | certify that I have complied with may obligations to file Massachusetts tax returns and to pay Massachusets taxes, and I understand that, pursuant to G.L, ¢, 62C, sec, 49A, my license shall not be issued or renewed unless I make these certifications under penalties of| perjury. 9) Teertfy that I have complied with my obligations related tothe reporting of employees and contractors pursuant to G.L. 62E. 10) I certify that I have complied with my obligations related tothe withholding and remitting of child support pursuant to G.L. ¢.119A. 11) Leentfy that I have complied with my obligations to file an Incident Report with the Board when certain adverse events occur in my privete office, pursuant to G.L.c. 112 sec. 5 and the Patient Care Assessment Regulations, 243 CMR. 3.00 et seg. [understand thet the Patient Care Assessment (PCA) programs at the health care facilities where I practice report certain Major Incidents tothe Board. 12) J certify that} have complied with my obligations to disclose my ownership interest in any partnership, corporation, firm or other legal entity to which I have referred a patient for physical therapy services pursuant to G.L. e, 112, sec. 12AA. ‘Check One: SIC] Wf Mave reviewed my Physician Profile at hp./profilesmassinedboard.org and confirm that the information is accurate. (Pease note that Ifyou changed or corrected your busines addres, business phone number, practice specially, board Cerificaton nd hospialafilinions on your renewal application, your Physician Profle wil also be updated) [1 Ihave reviewed my Physician Profile and auached a copy ofthe Profile wih comectons. Cl My status is Inactive and I do not have a Physician Profile. (See Renewal Instructions, page 11.) 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, 1 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. egg eeesceeaasc POA Yun Ww poe: £1 29 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 7Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Belsy § August, MD License No.: 59447 Current Status: Active License Expiration Date: 5/19/2015 4) Activity Status: Active 2) Address & Contact Information Mailing Address: 9 Colby Steet Salem’ Massachusetts - 01970 United States of America Home Address: Business Address: 9Colty Street Salem Massachusetts -01970 United States of America (878) 741-2600 3) Email Address: 44) Fax Number: (978) 741-1146 5) Speciatties Obstetrics 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 Obstetrics and Gynecology 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice New Hampshire 8) States where you were previously licensed None Reported 10) Work Sites List of allwork sites in Massachusetts, including health care facilities (where you are credentialed), private office, ciinies, nursing homes, ete WorkSite Location None Reported Paget of 5 Date: 31612015 ‘Tmo: 1:07 PMCommonwealth of Massachusetts wf Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.D. License No.: 59447 11) Care of patients in Massachusetts ‘Average weekly hours involved in: 9} inpatient care 20 rev 'b) outpatient care 40 hrs/wk 42) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEnd Date —_Policy Type. Coverys 1210172014 1210112015 (Occurtence 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 lawsuit was filed on that claim, or has ‘any medical malpractice claim been made against you during this time period? b) Pehing: Are there any unresolved malpractice clams against you today, ‘e., any claims that have not been resolved, settled or adjudicated during this time period? 16) Claims Closed Has ary medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been resolved, settled, or adjudicated during this time period? 46) Other Civil Lawsuits ‘usstion 16 refers 10 clsims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine 2) New Heve there been ary claims, other than mediel malpractice clams, fled against you during tis ime perk b) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, dunng this perioc? 417) Criminal Charges 8} Have you been charged vith any cmina ens auing Wie pod? b) Have any criminal offenses/charges against you been resolved during this time period? ©) Ave there any criminal charges pending against you today? 9) Are any Application of Issuance of Process pending against you? 18) Other Issues a)Have you withdrawn an application to any governmental authority, health care facility, group practice ‘employer or professional association? bby Have you taken a leave of absence from any health care facility, group practice or employer for reasons related to your competence to practice medicine? c) Have you been the subject of an investigation by ary governmental authority, including the Massachusetts Board of Registration in Medicine or any other state medical board, health care facility, up practice emolyet of professional ssosiion? ¢) Have you been the subject of a disciplinary action taken by any governmental authorty, health care faclty, group practice, employer or professional association? 419) Have your privileges to possess, dispense or prescribe controlled substances been suspended, » Tevoked, dented, resticked by of surrendered fo any state or federal agency? ee 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, 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? Page 2 of 5 ote: s6r2015 Time: 1:07 PMCommonwealth of Massachusetts & Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M.D. License No.: 59447 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 Pepe 3 of 5 Date: sn62015 ‘Time: 4:07 PMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Betsy S August, M0 23) Do you have a medical condition that interferes in any way or limits your ability to practice ‘medicine? 24) Have you used any chemical substance(s) which in any way interferes with your ability to practice medicine? Page d of 5 Date: 5162015 Tie: 4:07 PMCommonwealth of Massachusetts f&) Board of Registration in Mec Physician Renewal Application Physician Name: Betsy S August, M.D. License No.; 59447 Compliance with Legal Responsibilities Online profile: [a]! have reviewed my Physician Profile and confirm that the information is acourate 4) ‘uncerstand anc age to compy wth my obigtions ta report abuse or neglect of chieren pursuant to ieee Tieicac BA and | Unerstana tie ponshment for are to comely : | understand and agree te comply with ry obligations to report abuse or neglect of disabled persons 2) pursuant MOL. 18¢ seo Wan | understand the pune or aie fo comply. 3) | understand and agree to comply wth ry obligations fo report abuse, neglect or Financial explitation of ekierly persons pursuant fo M.G.L. c. 194 seo. 15 ang | understand the punishment for failure to comply. 4) understand and agree to comply with ry obligations to report the treatment of wounds, burs and other injures pursuant to MG Lc 112 sec, 12 and | understand the punishment for faiiure to comply 5) | understand and agree to comply with my obligations to report the treatment of victims of rape or sexual assault pursuant to MG.L ¢ 172 sec, 12A 1/2 and | understand the punishment for failure to compy. 66) J understand and agree to comply with my obligations to report a physician to the Board of Medicine pursuant to M.G Lc. 112 sec. BF, when | have a reasonabie basis to believe that @ person Violated ary provisions of MGiL. ¢. 112 sec. 5'or any Board regulation. | understand and agree to comply with my obligations related to charging and collecting fees from Medicare 7) enetcarioe m accoraance wih the Medeesre fee sohedule, pursuant OM GL c. 112 sen 2 | understand and nave complied with my obligations to tile Massachusetts tax returns and to pay Massachusetts taxes and | understand that, pursuant to M.GL. ¢, 62C sec. 49A, my license shall not be |ssued of renewed unless | make this certification under penalties of perjury Luncerstand and agree to comply wih my obligations related to the reporting ofthe wages of employees ® and contractors pursuartto MG. 62 Seo 2 Saou 10)! understand and agree to comply with my obligations related to the withholding and remitting of chile ‘support payments pursuant to M.G.L.¢. 119A, 41)| understand and agree to comply with my obligations to file an Incident Report with the Board when certain, ‘acverse events occur in my private office, pursuant to MG.L c. 112 sec. 5 and 243 CMR 3.00 et seq, and | Understand that the Patient Care Assessment (PCA) programs at ihe health care facilities where | practice report certain Major Incidents to the Board. 12)! understand ane agree to comply with my obligations to csciose ownership interest in ary partnership, ‘corporation. firm or other legal entity to which have referred a patient for physical therapy services, pursvant fo MG.Lo. 112.sec. 120A, 13) am aware of my obligations and responsibilities under the Health insurance Portabilty end Accountability ‘Act of 1996 (HIPAA), including the requirement that | ebtain and provide to the Board a National Provider Identifier (NPI) number. 14)| understand and am in compliance with HIPAA and all other federal and slate obligations placed upon me ‘asa physican, 16)! understand that as an applicant for a license renewal to practice medicine a eriminat record check may be ‘conducted for conviction and pending criminal case information only from the Criminal History Systems Board and that It will not necessarily disqualify me. [Ihave reviewed the above statements and certify that | understand my requirement to comply with the responsibilities and obligations of each and agree to do so. DX) Under penalties of perjury, | declare that | have examined this renewal application and all ofits accompanying instructions, forms and statements, and fo the best of my knowledge and belief, certify that the information Contained herein Is true, accurate, and complete. Page 5 of 5 Date: 3182015 ‘Time: 4:07 PMCHARLES 0. BAKER aN Commonwealth of Massachusetts ‘i f Board of Registration in Medicine 200 Harvard Mill Square, Suite 330 Wakefield, Massachusetts 01880 (781) 876-8200 www.mass.gov/massmedboard Governor Enforcement Division KARYN E. POLITO Legal Division Ueutenant Governor Licensing Division MARYLOU SUDDERS MONICA BHAREL, MD, MPH Erie Sorringon Re: Malpractice Cases for Betsy August, M.D, Fax: (781) 876-8381 Fax: (781) 876-8980 Fax: (781) 876-8383 June 15, 2015 CANDACE LAPIDUS SLOANE, M.D. KATHLEEN SULLIVAN MEYER, ESO. MICHAEL HENRY, 4.0. Secretary, Physielan Mombe’ JOSEPH CARROZZA, W.0. Physicin Member PAUL DERENSIS, ESO, Pubic tember R. MICHAEL SCOTT, 1.0. GEORGE ABRAMAM, M0. In response to your request, the enclosed contain the Superior Courts where the cases were resolved, the telephone numbers for the courts and the docket numbers associated with the cases. Contact the court direetly for all public information on the malpractice payments. Refer to the Section VI of the Physician Profile for disclaimer information on malpractice data Suffolk Superior Court Essex Superior Court 978-744-550 91-1896. 02-1272 '96-0439A. Zoraida Montes Public Information Coordinator (Msipracicecout0}