Before proceeding, thi + Remit $250.00 for renewat fe, Add aherations as required. 1. Curent Stats: Aciive 3. A) Maiting/Business Address: i JEFFREY M DRAZEN BRIGHAM & WOMEN'S 11OSP ' 15 FRANCIS STREET BOSTON, MA 02115 ‘eed copies for credentialing and other purposcs, ‘eucea envelope & wecks before your renewal dale, fee of $25.0, it necessary + Enclove check with eaupot In Please review carefully the following information for accuracy and completeness, you want to change your curent status, please check ane ofthe fulwing boxes ta indicoe your nedS Dacive CRRetising. (see instmictions) Ditnsesive (sce insauctions) Oona’ 2. Other Name(s), if any, under which you were licensed: ‘Teo West Street, 3rd Floor, Boston, MA 02111 (617) 127-3086 htip:/heww.massinedboard.org + Retura renewal application in Regismation No.s6149 Renewal ‘Please make corrections (lype or print) Commonwealth of Massachusetts Board of Registration in Medicine Physician Registration Renewal Application= oy You wilt ‘This completed renewal form with attachments must be returned in the REDACTED COPY Sikes Ramat sae [Business Address: SAW Ee ASA SQV er 1B) Lome Addeess: lCitytfown: see Coe See Zin Conary: ae Business Telephane:((,\"]_)_“TSA—>5 LF i fitome Address: aa) Cigvtown: Serre ee : aan Conners? a Home Phone: ome Telephon ‘Business Phone: PLEASE NOTE: No P.O. Boa addrevses for home or Dusiocss addresses, : 7. Curren American Board of Medical Speciahtes Geniication Soc Tobe?) 4. a1 Date of Binh bi Sex ee Sm 4 Wh iis Code aussi: 5. a) Name of Medical Schoo 8. Drug License Numbers, if any: a) Federal (DEA): by Massachusens: Dy MHRREREILIEN Stee) ey Dees: 4) | 9.21 Otersmes whee you ow end wpecie (ator) 6. Specialty Code(s) (See Table 1) Coders) ‘Hours per Weck in Mass. hn) States where you were previvusly licensed (Abbr.) GeNerie amar a cana PUD © Patmonary Dice c. vec ¥0. Current health care facilnies at which you have compleied the credcon ny process forthe provision of patent cave. (Supply Ress from Tale. ond place a check mark ext thoxe health cre factles where you have aduaiing privileges (A ‘Nexto each facility, write the proximate percentage of patient eae hours that you provide in each facilin) Facility Code: 1999, print name(s) (any Y% Fecilty Code: cate 7 es (pS. x 1 to com3 365. (AP) _S 9% Pacey Code 3A tar) -S% f(a) ~% Facility Coe: 7 _ (AP)PRINT your Last Name: @_ “D RALEN _ License NuMBER: Bol4O > 11, My medical malpractice insurance is covered by «) [5 tosurance Cassie b) [) Lener of Creat Name of laser Alternatively, indicate a follows 1am registering with Active ats but fam not covered by medial malpractice insurance becuse Lam (check one) 2) C Not involved in drcevindiec patient care in Massachisens. +) [Otherwise exempt Pease explain exemption: 12, Ae you curently in «post-graduate raising program in Massochusens aso residet ox clinal fellow? (check one) LC) Yeu Co 13. A. What is your principal work sening? (See Table 4) B. Care of patiemts in Massachusers (see instriction booklet). 1) Average weekly hours involved in: s)ourpatcatere 5) teak b) inpatient care <3 _tesivk 2) What isthe approximate percentage of your patient care hours in primary care? _C_% = QUESTIO) R S 14. CLAIMS MADE: Has any medical malpractice claim been made agnnst you that has not yet been finally Seitled or adjudicated, whether or nota Lasuit was filed in elation to the claim? 15. CLAIMS RESOLVED; Has any medical malpractice claim that has been made against you been settled, sdjudicated, or otherwise resolved, whether or nota lawsuit was filed in relation tothe claim? 1 16, Has any lawsuit, other than a meicel malpractice suit, which is elated to your competency to pracice medicine, * your professional conduct inthe practic of medicine, been fled against you or been seed, adudicted or outerwise resolved? 117, Have you beea charged with any criminal offense, other than a minor tfc violation? 18, Have you been charged with or disciplined for any violation of tows, rules, bylaws orsandards of practice of any goverment ahority, healthcare facility, group practice er professional society or assoeiation? 19, Has your privilege to possess, dispense or prescribe contolled substances beem suspended, revoked, denied, restricied by, or surendered to any stat o federal egency? 20, Have you withdrawn an application fora medical license or beea denied a medica license for any reason? 21, Has any professional lisbiliy insurance provider restricted, limited, terminated, imposed a surcharge or co-payment, a placed any condition related professional competency or conduct on your coverage or hive you voluneaily restricted, limited or terminaied your insurance coverage in response to an ingury by @ rfessional Labi insurance provider? 22, CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date? A Yes (No CMe Waiver requeted (CME waver frm due 30 days prior to dete of license expiaton) ____7) CME exertion ‘See Iastructions for CME requirements. Do not submit document: f your CMEs with your renewal application, Pursunn GL. c. 12,6 2 {wil no charge ta or collet (rom & Meare beoefciary more than the Medicare fe schedule amount Forsuaat o GL. ¢.62C, §49A, tthe bes of my kawwledge and belt, | have filed all Massachusetts sate ax return and paid al Mansochusen sate taxes that are required under tom. NOTE: Tols applies even Ifyou reid out-of-state or out of he Uried States. + Parsuant to GL c. 62C, § 474, tothe best of my Kaawledge and belle m in compliance with M.G.H.C. 119A relating 10 ithholding ond remlting Child Support + Pursuant to GL 112 § 14, Iwi ffi myebigaton te report abute or megs of children es requiced by G.L-e. 19,6 514 + Unereby certify under the penattes of perjury thet ell the information on the Renewal Application ond Form R ts rae. a ) e. MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. 2Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320 Physician Registration Renewal Application ° Before proceediog, please read the instruction booklet * Copy this form and all aachments for your own recards; you will need copes for eredemaling and other purposes. + Remit $250.00 for renewal fee. + Return renewal application in GREEN envelope. + Add late fee of $25.00, Ifnecessery. + Bnclose check with coupon in BLUE envelo Registration No: 36149 Renewal Date: 95/19/2999 1. Cument Status: po {you want change your curent status, please indicate below: (Check one). Dative Retiring (se instructions) Dace ectelow) Done Please make corrections (ype 0 [Other Namesy 3A) Mailing/Bueinees Address [Mailing Address) JEFFREY M DRAZEN, M.D. Cityrtown: ‘Sate BRIGHAM & WOMEN'S HOSP 78 YRANCIS STREET BOSTON, MA 02115 2, Other Name(s), if any, under which you wete licensed: B) Home Address: ‘Home Phone: Business Phone: (627)732-7420 4. AY Date of Birth: Sex: yy By SS#: 5. A)Name of Medical School: J Harvard Medical school eee EIS BY Year Graduated: 3979 €) Dearee: Year Graduated: Degree: MD. 1) Do. 6, Specialty Code(s) (See Table 1) codeisy ~ Hours Per Week in Massashusra | Code(s) Hours ner Week in Mass, Beet Care Medicine — |ifOS Print Specialty: 1-Camt Arian Bond ot Medel Spits eine Title2) PES =n ea ca Soa bg Lact theten er aheaael OX oeeuee ae 9. A) Ofer mac wees you un ed pra Abbr wy cq ee 2) sine wie Bvt wee cowed pce oe ase “I requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in MassachusettsPRINT NAME AND NUMBER: Lest Name:__Deazen Registration Number:_36140. UG, : + Bator procaedrg, pase read the Intveton bookie. i + Anewar el non-sptonal qvowtons complete. (The lnebuciensspacty which quostone ae option) * $0 aur pe i eeneel Aachen Your ann recrts-ye mus hest carts copie fo ccenieigpupctas. Te Bad aarges $5.00 plus postage foreach copy umithod. Enclte tho $160.00 ronowal fo by means of candied chook. money ochre chock mede payabe othe Commonwasth of Meseschutets ‘atid Satues ani pane es ep eon tine 1am applying io be rgietarod with th ftowng see! tnaotve tus, | wil nat prectioe medicine in Meaaschusetis, ‘Corrsctions of Prerintedtlermeton 1. Otar Manale any, under whlch you wero fone lene ees eeee ar EES RadAdeoes Homey: sein neraeaatneseaeeaebasesnegitansiaanaaieatesaeelsteed Ey tin 22 SSeS eee eee Premera su cou Coxe (886 we Comsy_—_ 2,8) Ade (usnes Asdrne a Soot EET TSRAEL HOSPITAL ciyrtome eeeoeeceataase 339 BROOKLINE AVENUE sie: Peccoeeescarcceea| BOSTON, NA O2215- county Gade (1900, wie Counye_—— Depot wn: Sox [es ti ean: Se Uc tne Onis 1/29/73 sane Ue. rev OasewaM aan Teephone Nebr Home uate Mome:(_ putas | , CTP) 735= 4020 + waist sctnlCodetO01 Yourcrnuned7 2 Onge:8 | tel cose,__ Your Gratowtt___oagroo (w01005_| ‘Name Shoal 96689, wit School aes Harvard Medical School 6.8) Otor Stave whore you are now Kconsod i pact (AbnyNY CA a ) Stabe whore you prevouly wore loonaad praia (ABD): ae 8. Spocioty Code(s) (Sev Table 3: fade Hown.ear Wonk in Mans, Pud O Pulmonary ofseases 0 74) Ar you Anavcan Speiaty Boers Certed? (NY 78) VES, Ent’ Godor Cows: 1M Board of Internal Mectcine Cote Cod ade 8. Drug Lcenao Numbers) (any) foponaa) Federal (DEA) ) Sat (MA) ses © | havo compiead my CAME regrants toto two years pracacig my ronowel des: YES_X_ Wabver Roquosted__ (rou aus 8 8 toparate Weaver Form, The wolvar mut bo grated by tho Boars bolas your Icanea wt be renewed.) Seo nssuenens fe SHE ‘mqulemants, Do not suteit documaniaton of your CME’s with yur renewal apetcaton, sou - 80. parsers {For cttee Use Oni: Waiver Graniod __Ootm_) p_y ) How many DEA 908, de you have?FILL IN NAME AND NUMBER: Physlelan Last Neme:__ Drazen. Fogisraton No.3 6 1 4 0 10. My macica malpractice inurenoo i covoreé bye) NSURANCE CARRIER_X_oy (0) LETTER OF CREDIT____. it dophombo, chock ona ! st Ianwor,_CRICO Ateratvely. incao a9 flows: |e veqistrig wit ACTIVE ave, bil en wo eovared by mecha malraten iano bosauso em (Shock op {NOT INVOLVED IN DIRECTANDIRECT PATIENT CARE: OTHERWISE EXEMPT: (State how etarvise axampt! a 1%. Curont Hosp Attatons (opp the cod hom Table 5 and piace a checkmark not tate fates uber you haw adnitg veges (AP). : Fecllly Cade:__69_ 1x(AP) Factiy Code: 44 1 WAP) Fecity Code: 139.1 AP) ‘ Fy Code:.2.2L Ar) Fasiy Cale_3.25.L.NAP) Fay Calo:___ in 11090, wre Nemo) ‘Aeivaaltgyaas ot wich you cause hall peogoe and thr Heals Care Feces wit which you war aasocaed hw pata your Fest Code: FaclyCotu:___ Fact Code: = 17880, wet Hamels 12 Post Graduate Training in Massachusets (MA) (Seo Insaucion bookit) ) Are you curanty in port gradunts ahing program in MA a a rosidant © cnc fatow? Yee No_k_ (Chock ona) ©) Htyou ar in a MA progam, am yous |) Reeklant__ @) Ciel Felow___ or ll) Rasoerch Fetow,_? (Chock ona) ©) How many hours per plea! wewk co you spendin thie MA poat-graduato Tuning program? ik. n WA 18, Goro of Pegonts In Massachutons (MAY (Sap Iatrueon bookat) 18) Hom many hours er yploa week ar you curanty lveved in cufpaint care fn MA?_2___ hrs. MA, 1) How many hour por plea week are you curently inves in nptiont caw in MAB Frew, in MA. "4. Principal Werk Satiag. ‘8) Woatis your pinelpl werk sting? (See Table) 4 5. ‘Queatlons 16 through 22 role tothe pest tout vears only. Check alther VES at KO (net WIA) lo gash question. Provide detela on Form 184. Yer, Ne. 1. Hes ery paning or naw maoal malarcon claim boon med aga you (whether or rot Lnwetit wat fed in olan wo the din? "6. Have you boon a defendant in ay ponding ci now criminal proceeding efor than e minr all offers. 17 iw any fool cacptnay charges ponding or hes ary cacinary acon (ee cetnod by Board roguatons-Goe ieee boon akin asin youby any Govesnmenta auhony,hogptal or othor hoa cern fai, or proonsinal medial esvocaton (ntmatonal, nasoral ‘tat lol. a 7 16. Has your pvoge t possons sponta or presario conrobed substances boon sutpended, revoked, Conlod,eebcted,surendored, ‘hve you boon calad olor or boon ward byt state or any ober ura nciing fede ageney 18. Have you windrawn an eppcation fer a medica! Koonce or boon donc a medal Beane 1 Bry FOREON? ns ecwene ne | 20. Have you had any mental oss which has impaled your ably w practice mexlkne or te uncon asa sidont of modein?, 21, Have you hed an args lnaea which has inpires your eit to practic madcine ort func asa sido of modicho?. £2. Are you pow, oF have you boon in tho pastor your, dependent upon alcohol o dupa? Pursurn! 9.0.1. 6476, }wlllnot charge to or colect tram « Madtcere beneficiary more tan the Madioar reasencblecharpe let my series, Eirruent te W.GLL C620 a0a.48A,lcerity under the penalten of perury that to my best knowledge and ball, {hae fled any Maseachusett este SLR Ad palé any Masanchusste stato tax, tht ate requled under law. NOTE: Ths epplen even lf you rede aur-ct-atate or euro the country. {cary tht wit ttt my ebtgetion to report ebuse or nogltct of children pursuant to M.QLL.0.138 s0o.81A. | hereby cority under the ponelles of perry tha all Information om thie form and Form 18A le tv. oe $3232 AB, om 3 IS YBOARD OF REGISTRATION IN MECICINE: SEE REYEREE supe euwesrsrsest oe REALS ro comer re ov sosron wassactuserrscan BE Ly. Ho | ERS au MOLE RSE RSTO RENEWAL APPLIGATION FREE vee vo cursos 1 1987-1989 ‘ Sunguanhs, You must ouede mms BO Sy Pearse he eco nu anor AICENGE NUMBER PAY TS Fee pSeroes smmewee | LATE FEE “TWIG APPLICATION MUST BE SIGKED ia Bammer | _ AMOUNT Peo as Te NOTE! Ne RerunnaD Wine Anau Pa MD 1 36140 $100 | 100 87 SHEN is MENA BEROSMAL PAYABLE TO: ‘COUNONWEALTH OF MASEACHUSETTS ‘TEN WERT STREET. 214 FLOOR SOBTON, MASEACKUBETTS 0211 pestis tea JEFFREY M DRAZEN YOUMUEY READ THE NSTAUCTIONSENCLGGER WT TH FORM TO ANEWER QEBTIONS V2. = = eae sore, 8. O66 OB ag 3 Moea'sonox: Hazvard __ 7 BF 0.07 [] ccrwexoney 4. Country whore Medica! Seheot ecetoa, USA 5 O0t0 of Gracuniton. Aoaean Sct Sars or? [RF (rect ten) vines town —-108erDal Medicine § Pulmonary Pulnonary/Internel Hedicine June 1972 1. Paneal Satta Hospital Group Moma edéras: a 1 Piet work ating 10. Pipa busnom accrets, Beth Terae] Hospital 330 Brookline Ave., Boston, MA 02215 1. Ltatnostan ot wicayoutun eutenty tec prvieges, —BE2gham & Nonen'a, Beth Iereel, Nentucker Covtage 1, Lista poaptas won you nave hold pridage In tn pant 20 yea: bove ‘California, New York 3%, Hat any mecca malaria cir eon made aginst you iain as tn yas (wna roe tau Wasted triton iho int ‘ha you, at ery tine bean defencenl a ony ermine proceeding ether hen rior Vs olonsee? bi parse utnitieeety waa aster PEL eaaT others you Srocin anspor meee ee ea | el 18. Hove you mar who an pptation fr acc Ranke or en ei dl Henna or ny rust 28 Har you ev naan menu ina whieh hs inpaea you eb wo pactce medicine at uncon ew eudeal nese 2, Have you evr had a organ aes wich ra np your by io practice madera at neon 32 Ar youu, orbave you bein ho pas sepancent upon aleel or ervgs? 28. Heve you ews, fo any renson, ot Areca Spiny Goaré Caneaton? oe 3s ely sent mina aa Yat whi ee? 24. ( have complated my C.A.E. requitemanta in the two years ending on the renowaldeteas totiows More than 100 hours Ci CME credit 48.40 neers [9 mecne []orctona (nek One) tgaley cemnry UNDER 1H PULTY OF PERJURY THAT AL MEORMATON OM TIS FORM FROKT AD BACH INCLUD ATACHE SHEET 8 TALE SURPUINT ZO GsATER 48 OF THE ACTS OF 18s, WAL NOX CHARGE 70 OR COLLECT FROM A NEDIOARE DENGFCIARY MONG Tha Tae NEDIGATE REASON BURSURIT TS MOL. 62 § 40 | CERTEY UNDER THE PENALTIES OF PEAWURY THAT 70 MY BEST KNOWLEDE AND BELIEE HAVE FLED AL STATE Tax ERIS Si APN EAE PLEASE Wore thls APPLIED EVEN YOU RESOE GLY SeSTATE OR GUTOE TE COMMAS . (Gen Reve 50)“Ten West Soe, dr Foor, Bocton, Masanerusets 2411 ‘w= Commonweanh of Messachusots Beart of Rogataion in Medielne 696089 1869-1981 Phyailan Hoglsvetion Renewal Appizaton, Page 1 ot 2 foie ree presen ee age sea ‘eran atten att entree sce rnetmanes apie macnn eee ae ae a wea me Soccevietiats meres sara coe cout eee a See apm St Dreren 1.8} 00a Mane ny ays wee oa a ajnoae pusingh. Pulzonary Bivieton, 2D BrockLine Avenues, 2) As era 2 bees Bena Sabe_ ae 2 feepton Beans GT )1 3. 20 ena ‘ortega on Optom 3.0 Be OAR “Sec LE PEAMLE_———_—&. Set Sanat, a: 1) Mc Sec Cae (Se To 9H. 0.1, 5609, rt a, eu YarGatumt 72 eg ongee MOK 0 (6. Omen, LS. Crmae_ Coda Oe nT: HO tn ae 1. tig (ita tea aca Pci Pe ‘ore ton Sree Otee x sone * ‘hat eats Car = ‘oro0 ray * SS eoventonaon x _MOvenmetaatty (eParCoremn Cong (eter! ety (Cc nd an Pan a Pol Fou: For "22 Pci ion Ou Psat Care oddone antes “IGN oa Txtng Gaiden “38 tw ©. Som Cave fae eb 3B Prat acon Tn 00% Spey Cae: _ ie RD 00. 1. Ayu Aros Spc Gawe ortec (VT aS cab neh Bota ues etsy nei eu ot tar ce KX Seeaetacetnecegy 25 Seat ei rasogy GAS feardetGaon oeslSugey OP bene nung) DY Seercernatany 88 Seuset rayon Sen, EM board Emergence, OF Bowe ststyeaseny Em SeurgatFamiyPacen Ph Bourdon Cooper) Pe Sudo resenst 0 tena tee eerdorhaegealSucey PAIR Bowdon & Raat 1.4 Apt ach you ne tan tine pies nda Maa Ge acta wn hos Wa Pectin Tn tan. (aur tae) Facty co 06.9. -ag_* faty Cote 3.3.5 1X Fay Soe: feat oome 93) SETS Fromm one 333 OE ‘ay ee 61, a Na "1.3 Aion apa a ov ru pega de ei a Fclenwih wach yu wma Pape TR een a "haa sry att raevnrg MACTWE wu, retraction made Mauna, ‘avast occ em 4 Wace anata ova thane Mdn resonable age ey san ‘aoa ithaca rca ay ag arm trea ‘sotto pn ey ote nt -aaifl- hda JEFFREY 84. DRAZTI eee ow BLO, SF‘Massachusots Board of Reglevaton in Medicina 19501991 Renew Applicaton, Page So ‘ia nune creme, Pryce an Mone Drazen agaraon Has 3 6 14 0 W.a)Oon Sumnenen yous non termes pastes WHOM) yk, 12.0) Boab dey we tera a pn Hobe Siantschoeemngnensainoetmiogmnn Shee kee Hebaecmamsm eine” “oes meen mes tere wt (agement ea) ‘wee Rear (omen Tota ape ake) * i "any nen msn ren ot ty MEURINCE CANEER_E LETTER OF CREO _ Yast, eck rte ne mace, inches big att Ce ‘rar TEER wwe aang wa RCT sab et sed RE IDRC PTT TROT OF MHOLVEDIN OECT/NDAECT PATENT CARE OTMERMGE DEAIPTED.” (St he, 1c Pooemet ran Tne nice 100% Cote tem a ato Cn Ne AN whom, Pn hon A {5.han ay pati or eee madi malneoa antao muse ag ts fn em wa fn non en. irr yo ba catenin ey onc Yaw cnn! ram tn ah ee "gama eee rs sr tet ee ne Baste asi {tye ener TES" qvetn 1 16 oF 7 prota on For 8A sande. orton 1 ci 3 taney Cc er ES nA Eh en, Prone nett. Yon he SSE REL tnt ee A ye ea en Sey msn mao {9 Hav yu whim a tpiton a ac ona ban Gemalto {Me youre any nal rata st ht pi yor ye pind ren a aa eyBOARD OF REGISTRATION IN MEDICINE IMPORTANT ~ READ, COMPLETE AND SIGH — ‘ROOM i507 ~ 109 CAMBRIDGE STREET fussunn’ ro ua are. veoh 1 cennEY BOSTON MASSACHUSETTS Oosos RORY nTAMBS of IE BM CORY RENEWAL APPLICATION SINCTAC AC po tn Pais STATE Tatts 1886-1988 AEB Uae Bro aoe ae YOU MIF Sen geiow TeeNseRONER oe | ee [eeesmenne] cveree SET oe nour autpe wane ND 36140 100.00 |100.00) 01) 15) 86} ; Ra OR # JEFFREY M DRAZEN e = af eR ‘Ste ReveRSe SOE ‘YOU ane REQUIRED 10 COMPLETE The OUEST BEET KNOWLEDGE AND BELIER HAVE FLED ALL OW THE REVERSE SIDE OF THIS APPLICATION. (RE {TW ENCLOSED INSTRUCTIONS FOR DETAILS) 1 YOU ANSWERED "YES" TO ANY OF THESE CUES jos, YOUMUST CHECK THs €0x:_] PLEASE USE THE ENCLOSED RETURN ENVELOPE {THiS APPLICATION MUST a SIGNED AND NOTE! jervanen Witt A sio0 earuene & SEnrinea CHECK Gn wOney Onsen 18 BRerenneo, PERSONAL CHECKS AME Dy CREE, 7 PavAave TO: AHL CommonweaLs OF MASSACHUSETTS P.0.80x8 BOSTON, MASSACHUSETTS zu? 3500600361402 011586 10000000004 eeon mow, erence M4. Dre: Modest Senoot HBR VRAD Tone 197-2 2 Principat work song: Chou PHAGE 1. Plait Soaeny is 2. Wome ima: EEE tet 4 Pun! usin econ pecnay Drurtrtsd ae Gen Tsents Aepera = S Lcangagnaten ou me corny ate ante ‘Alomous, Bem Fiaate NM, rae hil fantinasbenssos in UlitWou ae icensed te pactes: WF CA ns is ae ‘vey ee lt ny main alco nen) rc fat ays etn sna ny min puntg ear nn or alan command sr WAST : ray ia el ar aut pe Wy RH oN SOT ROT TOS OTT oo satan naa ane Se ‘Eten you eae some dotepnalv embed wisn eben ipod H aT Tae TTS Hu thoeconsned my CME gunman ton Vek ite wine COR SD Gens T Chto | 18, Jaman ave <2 rcv. —___ pation ac re) UREREGY CERTIFY UNDER THE PENALTY OF PERJURY THAT THE ABOVE INFORMATION 1S TROT ws, ~ (YOU MUST ALSO SGN THE PRON OF THs CHRD) iSRATOREDIVISION OF REGISTRATION portant — acAD.coMPLeTe AND Sion MY SAUNAIUKE UN FHLS KENEKAL 1 HRS Re qgB8ChMBMOGE S7ncer — Funaueny Jo wisi cen: San rctsity APPLICATION INDICATES oat fT HOSEN EWAL ABPUEATION ee HET MuOWEGOE puoectcr taut FuiSeat” ATTEST UNDER THE PAINS AND BOARD OF REGISTRATION — feouineo inaem an” SO MSTAETINES DewAL TIES OF PERJURY TU THE IN MEDICINE segs COMPLETION OF CONTINUING ep EDUCATION REQUIREMENTS IN AS A REGISTERED YOu MUST SIGN BELOW COMPLIANCE WITH THE BOARD'S PHYSICIAN STATUTES AND/OR RULES AND ae yt {noon OR EIA TONS te ree ey PLEASE USE THE ENCLOSEO RETURN ENVELOPE. poets eceeelee aa ‘Note! RIBAS GRTI, mast a SOME ag 7 sharma Woke Seon” Atal BS 8 x § JEFFREY M DRAZEN a a COMM. OF MASS. ee P.O. BOX a — a BOSTON, MASS. 02297 85 d/ uwoenurien rensowas cuEcKsausiNess ei wie iin ni vin hecxs wick nor se accent. 3500600361402 011584 Logv00000092. Principal work satting: * LF |G | 4, Primary work address; BaorAnP Abmews Mose FS EAnoscis $7, Betzan) — NL GA +. Pincioa srocinyoon * [¥ 18 [7 | 3. Home Aagrass 5 other than Massachusells in which you ate siconsed to practice: mH 8. Hae & Judgement ween roturned against you in a malpractice suil since 115/827 17 Have you ever been convicted of any criminal olfensa other than minor trac offenses? 8. Has any disciplinary action boen taken agains! you in this state or any other? ‘Has Your piivilege (o-pusgoss, dlapense or pesciibe conivolied eubelances ever been suspended OF THGKET ~ linthlg sige ov any otner? ols | HEREQY CERTIFY UNDER THE PENALTY OF PERJURY THAT THE AUOVE INFORMATION IS TRUE, | "SEE CODE SHEET wou. 10. | have completed my C.ML.E. requiroments between 1/15/62 & 1/18/84 as follows:Commonwealth of Massachusetts Board of Registration in Medicine $60 Harrison Avenue, Suite #G-4, Boston, MA 02118 —(617 Y = a ‘need copies for eredentisiing and other with attachments must be returned in the on sreen envelope at least d weeks before your te ‘+ Remait $400.00 for renewal fee (non-refundable), {Return renewal aplication in GREEN envelope, 3 Add late : Please review carefully the following information for accuracy and completeness. Make any corrections or alterations as required. All questions must be answered or your renewal will be delayed, 1. Curen Sas: Active Regiseation No36140 Renewal DateDS/19/2003 ‘you want to change your current sta, please check one ofthe following boxes to indicate your new status: (Check only one) BActive —— C) Retiring (se insucions) J nactve (eee instructions) (C) Do not wish wo renew 2. Other Name(s, any, under which you were license: coer eee cre) ‘GME ae Cotter Name(s) C7 Name Change (ener name below) 3. JEFFREY M DRAZEN BRIGHANTE WOMENEHOSP Mailing Addresg. EV Cateaws Sovanaece ACERT IS ERANCIS STREGTPOWER48, CityTown: 105 7 Stare: Fae BOSTON, MA 02115 bets eae ee my ilige a B) Home Address: 7 [Business Address CigyFown: Se Zip Couns Business Telephone: (___) ‘aires ci ‘Saae: Home Phone: te Country oat ; Home Telephone > Business Phone: (617)73.5729 PLEASE NOTE: Only one address can bea P.O, box. The malting address cennot bea P.O. Box, 4 #)Date or Bint: bisex: —-M | 7. Curent American Board of Medical Specialties Cetfcauon (See Table) Cade:I M04 Code: IMI ose 8 Drug License Numbers, 5: s) Name of Medical Schoo! 1) Federal (DEA), Harvard Medical School iy iamaone, ) Year Graduated; Da : store PERE ay, 9. 2) Okra where you re now ened pete (AB) 6. Specialty Code(s) (Sev Table ) & Code(s) Hours per Week in Mass, b) States Where you were previously licensed (Abbr) PUD 8-5 Pulmonary Diseases Ea sere amie seerereree ccm “5” Critical Cae Medicine eer te reeeeee Peete eeeee cae 10. Lista cursent health cate facilites at which you ate affiliated or have completed the credeatisling process forthe provision of patent cate. (Supply the codes fiom Table. and place & check mark next to those health eare facilites where you have admiting privileges (AP). Nex to each fectty, write the approximate percentage of patient cae hours thal you provide in each facility). No affiatons, Facility Code: 9 2) ¥ (AP) 9D_ % Facility Code:S 9 01 (av) 7 % Facility Code: | 39 /-_(aP)_O_ % Facility Code: 44 17 (AP) OD % Facility Code: 3 8 5 /~ (AP) O_% Fecilty Code —(aP) % 1999, prin nares): ee| PRINT YOUR LAST NAME; RABE LICENSE NuMBER: 6/4 > 11, My medical malpractice insurence if covered by [Insurance Carrier © []_ Letter of Credit Insurer's name, (Required CRED Policy dues: From: | /_1/O3te: 12/3/03 Alternatively, indicate as follows: Iam registering with Active satus but I am not covered by medical malpractice insurance because Tam: Check One: [) No} involved in direcvindneet patient care in Massachusetts [A government employes. Cotnerwise exempt Please exlaiexemprion:_-” : 12, What is your printipal work setting’? (See Table 4) S_ © IT you ere affiliated with healtheare facility or eredentialed forte proviston ofan cre our comple ui 0 o pag. and st ou afin, 13, Care of patients in Massachusens(sbe instruction booklet) i 1) Average weekly hours involyed in: A) inpatient care Jhrw/wk —B) outpatient care __bre/wk 2) What isthe approximate perpentage of your patieat 4. } Has any medial malpractice claim bees made against you that hes not Yet beon finely setled or adjudioned, whether or not a lawsuit wos fled in relation tothe elnisn? . Has any nhedicat malpractice claim that hs been made against you been settled, sdjudicated, or otherwise resolved, whether or nota lawuit was Sled in relation to the claim? 16. His any law, other than a medi¢al malpractice sui, which ia related to your competency to practice medicine, ‘ot your professional conduct i thelprectice of medicine, been filed against you or been seitled,edjudicated or otherwite resolved? 17, Have you been charged with any criminal offense? 18, Have you been charged wlth or ditpiplied for any violation of laws, ruler, by-lawe or standards of practice of ‘ay governmental authority, beslth cee facility, group practice or professional society or association? 19. Has your privilege to posses, dispfnse or prescribe controlled substances boco suspended, revoked, dened, restricted by, or sunendered to any uate of federal agency? 20, Have you withdrawn an spplicatioh for s medical license or been denied & mndical license for any reason? { 21. Has any professional lisility insufnce provider restricted, limite, terminate, imposed a surcharge or co-payment, or placed any condi relied to profesional competency or condua en your sovene, or have {you voluntarily restricted, limited or terminated your insurance coverge in response fo an ingury by professional Liebilty insurance provider? 22. GME CERTIFICATION: tev conpeed you CME reuters retin your teal nt Bre CNe Oy ise Waiver. CME waiver fem must be eubmied at leat 30 days prot to license expiration date, Ci Imetive san )_Resideney/Fellowahip tining (See instructions). See Instructions for CME waivet or exemptions, Do aot submit decuraentation of your CMs with application. + Pursuant to Gil, c. 112, Sec If, I understand my obligations to report abuse or neglect of children under GL. c. 119, Sec. SIA ‘nd the punishment for flue to comply. + Pursuant to GL. c, 112, Seo 2,1 will not charge to or callect from a Medicare beneficiary more shan the Medicare fee schedule ‘mount + Purmuant to G.L.c. 62, 4941 cenify that Ihave complied with all laws of tht Commonwealth related tothe fing of Motsachusets state tax returns and payment of all Massachusetts stato taxes; reporting of employees and contractors under GL, 628; and withholding pnd remiting child support pursuant to CL. c. 119A. (See instntions). 1s. 1 hereby eerily under the peaaltie} of porjury that all information on th Renewal Application, Part B and Form is true, MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING.Massachusetts Physician Renewal Application Physician Name: JEFEREY M DRAZEN License No 36140 PARTA 1) Current Status: Active Ronewa] Due Date: 04/21/2008 Hirth Date: 4 you want to change your current status, please check one ofthe Following boxes to indicate your pew situs: (Check only one). (See Renewal instructions, page 3.) L_D active OD Retcng © imctive Do no wish renew 2) Addresses & Contact Information. Please confirm your adUresses and make changes, I'neccssary. You are required to notify the Boned of Registration in Medicine within 30 days of any change of nddress, Home and (Gusiness addresses CANNOT be Host Office Box 20) MAILING ADDRESS: Please make corrections (print) New England Jura! of Medicine tae 10 Shack Set re Ades Boston, MA 02115. CityrTown:: Ste: Zp Country: 1 Cheer hag nates 2») HOME ADDRESS ee ciyrtown state: eet ti County: Pho: Be bid sptboene: (hed ere toch oe adress cannot be «Post Office Box 2e) BUSINESS ADDRESS MN 23 MST han ‘New Englah our of Medici 10 Shatock Sree a owh: site Hosta, MA G21 eget tlieinn ey i Susie Telephone: Cho Pere chang ree Busines ves connor be o Pas Office Box 3) E-minld Address: Fax Number: B7Z= iF 5) Specialties See Renewal Insirwctions. page 4.) Delete? Pulmonary Diseases o Critical Care Medicine o o 6) Current Ameritan Board of Medien! Specialties (AGMS) or Aorerican Osteopathic Associ (Gee enclosed insiructions and Renewal Insiructions, page 4.) Jon (AOA) tnformatton ist Certifying Bowral) blows Update General Certientes and Subspedialiy Ceriictes slow. Please ald addtional Cetieatton as required, Board Name aumsor aoa | cerieateSubspesat Correct? eta? Mngt ME ae C0 | Cries care Medicine oo Pulmonery Disease (ates olajo o az o o o o ofojo Page 1 of 5 2S) ogs0ez EO {5hMassachusetts Physician Renewal Application Physician Name: JEFFREY M DRAZEN License No 36140 (See Renewal Insructions, poge 4) Please make corrections as necessary 7) Drug License Numbers, ifany: 80) Other states where you are now licensed (o practice (Abbr.) 8) Massachusetts: ENV EECALECaaEHEEEaE See eeeeeCaae ) Federal (DEA: ‘8b) States where you were previously licensed (Abbr) ©) Federal (DEA) XS: 9) What is your principal work setting? (See Renewal Instructions, page 4) | Principal Work Setting: Medied! Society Change to: Please enter the approximate number of work hours at your principal work sétting: 72 10) List all current health care facilities where you are affliated or have completed the eredentinting process for the Provision of patient care. (Supply the name of the health eare facility from Reference Table S on Page 16 of the Instruction booklet). Next to each faclity, write your staff category at that facility (Admitting, Active, Courtesy, Associate or Consulting), and the pproximate number of hoars of patient care that you provide at that faciliy. Include any ufftatlons with on-line prescribing services or compantes. Please provide all information for additional facilites on a separate sheet, If necessary. Ne fttations C) eas ene he anatinate ber of wakhour fr each Heth Car at ow Mein Cae Fai Se Reel ine) [se] coos RL, ag Bath el Dencones edi Crier fing zy Boston Neel Coner Aamiing 7 tena ‘nace, : | Children's Hospital o U, Dane Farber Cancer institute goo/o/ojo}a + { [ 11) Gare of patents in Mavsnchoss (ee Renewal harsctions, page 4) |, Average wee oars involved ine) inpaonare 9 hsywk Change to: __ rk Dougan care __O hsv Change to: uv 12) Medical Liability Insurance tuformation (See Renewal Insiructions, page 5) My medical liability insurance is-provided through: (check one) Of tosurance Corver (complete below) (Current insurance Carrier: CRICO Change to Policy dates:| From ZI7/OS To A216) OF (required) 1D hatter of Credit subject 19 Board approval fatach o copy) Tt am registering with Active status but | am not required to have medical lsbility insurance because Check one: {Not involved with director indirect patient care in Massachusetts Gi Government Employee Federal Tort Claims Act (FTCA) Gl Otherwise exeimpt Please explain): Page 2 of 5 estonsoneen 8stMassachusetts Physician Renewal Application Physician Name: JEFFREY M DRAZEN License Nox: 36140 13) Do you perform any surgery In your office? (See Renewal Insiuctions, page 5) Yes» No Hes, please complete Form PCA-O "Office Based Surgery” In questions 14-21, the phrase "time period" refers te the following; all time from the day you signed your last leense renewal/application, to the day you sign this renewal appliention, inclusive, (See Renewal Inurucions, page 5) ‘You mast check either YES or NO to each question. Provide dels on Form R Ifyou answer “YES" to any questions, Reve to Renewal Instructions for edditional information and definitions. ALL questions in this section must be answered, YES NO 14) CLAIMS MADE 4) Nev: Has any medical malpractice claim boen made against you during this time period, whether or ‘ot a lawsuit was filed on that clei? ) Pending: Ate there any unresolved malpractice claims against you today, any cluime that have not been finally settled or finally adjudicated? 18) CLAIMS PAID Has any medical malpractice claim against you (whether or not a lawsuit was fled on that claim) been resolved, setled or adjudicated during this time period? 16) OTHER CIVIL LAWSUITS ‘Question 16 refers to claims oF nctions related to your competency to practice medicine or your Professional conduct in the practice of medicine, 4) New: Have there been ony lawsuits, other then medical malpractice claims, been fled agains! you uring this time period”? ') Resolved: Have you resolved, sertled or adjudicated any lawsuits, other then medical malpractice claims, daring this time perio?" 17) CRIMINAL CHARGES 8) Have you been charged with any criminal offense during this time period? +b) Are there any criminal charges pending against you today? ©) Have «ny criminal offenses/charges against you been resolved during this time period? 18) Have you been charged with oF disciplined for any violation of laws, rules, by-laws or standards of practice ‘of any governmental authority, healthcare facility, group practice or professional society or association? 19) Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, nied, restricted by, or surrendered to any state er federal agency’? 20) Have you withdrawn an eppliction for a medical license, sllowed «license application to become obsolete ‘or have you been denied a medical license for any reason? 721) Has any medical Habit ero vied Tne rminatd, pone bccarge co-payment or paced any onto elated io profesional eompreny or conde coven overge ot fave you volunarily reseed or teinated your suronce coverage mespore on heer oy L__etmede ait insronee eure? 33) CME CERTIFICATION #) Have you completed your CME requirements preceding yourenewal date? Ves [3 No 2) na ae you requesting» CME waiver? Check to request CME Waiver. A CME waiver request form must be submitted atleast 30 days prior to ‘your license expiration date, See Renewal Insiructions. page 8) ©) I you are exe from CME requirements, check reason for exemption. (See Renewal Insructions, page 8.) (CME EXEMPTION: (check one) [Inactive Status (1. Residency/Fellowship training Page 3 of 5 e1oesoRzED 65tMassachusetts Physician Renewal Application Physician Name: JEFFREY M DRAZEN License No: 36140 PHYSICIAN PROFILE 1 Ihave reviewed my Physician Profile at profiles massmedboard.arg end confirm that he information is eccurae, 1 ss reveed ny Py Poie ad euche iy ofthe Profle wtcomstns 1) Mystatus is Insctive end I do not heve & Physician Profile. (See Renewal Instructions, page 10.) CERTIFICATIONS 1) certify that | have complied with my obligations to repor abuse or neglect of children pursuant 10 G.L.,¢. 119, sec. $1, ‘end f understand the punishment for failure to comply. 2) | cenify that | have complied with my obligations 10 report sbuse or neglect of disabled persons pursuant (0 G.L.c. 19C, see. 10, and I understand the punishment for failure to comply. 3) feentify that | have complied with my obligations to report abuse, neglect oF Fiat pursuant 0 G.L. 619A, sec. ial exploitation of elderly persons ‘and ! understand the punishment for failure to comply. 4) certify that | ave complied with my obligations to report the treatment of wounds, burns and other injares pursuant 10 Gul. 112, se, I2A, 5)! certfy that t have complied with my obligation to report the treatment of vietims of rape or sexun!essult pursuent 19 Gike, 112, se. 124 17 6) certify that 1 have complied with my obligations to report physician to the Board of Medicine, pursuen 10 G.L. €. 112, 426, SF, when | have a reasonable basis to believe thet person violated any provisions of G.L. c. 112, see. 8 or any Board: regulation. 7) ceniy thet 1 have complied my obligations related to charging and collecting fees from Medicere beneficiaries in Accordance with the Medicare fee schedile, and | understand my obligations under G.L. 112, se. 2. 8) certify thet 1 have complied with my obligations to file Massachuseits lax relums and to pay Massachusetts tsxes, and 1 ‘understand thet, pursuant 10 G.L. c. 62C, sec, 49A, my license shall not be issued or renewed unless I make these cectfications under penaties of perjury. 9)! cestify Ghat {have complied with my obligations related tothe reporting of employees and contractors pursuant 0 Gil 028. 10) cenify tat | have complied with my abigations related tothe withholding and remiting of ehild support pursuant to G.L.c 1198, 11) leery tht 1 have complied with my obligations to file an Incident Report withthe Board when certin adverse evens ‘occur in my private office, pursuan! to G.L.c. 112 sec. 5 and 243 C.MAR, 3.00 et seq, and I understand thet the Patient Care Assessment (PCA) programs a thethealth cae fcilities where | practice report certain Major Incidents tothe Boerd, Under penalties of perjury, I declare that I have exantined this renewal application and all its accompanying instructions, forms and statements, and 10 the best of my knowledge and belief, the Information contained herein is true, correct, and complete. | 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. Dare: F 1022) OF ‘Signand MaKe A&Q WN AND ALL ATTACHMENTS BERORE MAILING, FOR YOUR RECORDS, OTHER PURPOSES. Page 5 of 5 esionsnbege tgOr. Jeffrey M Drazen Data higgrse Number: 36140 AL DE? (NPY ‘The primary purpose ofthe NPI isto uniquely ide tty healthcare providers as “health care providers” in HIPAA standard transactions. ‘The NPI will replace all other identifiers asigned to health cae providers, such as those assigned by health plans, government programs and health care purchasers for purposes of conducting these business transactions. ‘Under the final HIPAA NPI Rule, al individual and organization covered providers willbe required to obtain an NPI by May 23, 2007, In order for your ticense to be renewed you must take ane ofthe following actions: Option |; Supply the Bosrd of Registration in Medicine with your valid NPI. You can apply for an NPI directly by using the NFPES web site a ww, hhs-20v. xsion 2: Cetfy you have personally aplied for your NPL and you have not received tye. Once you have received your NPI Number, F; ‘you must notify the Board. Please compiete the NPI form atthe Board's web site at www. massmedboard erg. ‘Option’; Certify another authorized institution bas applied for an NPI on your behalf and you have not received it ye (supply institution’: name), Once you have received your NPI Number, you must notify the Board by completing the NPI form et the Board's website (see Option 2). Qntion 4: Authorize the Board of Registration in Medicine to apply for en NPI on your behalf. ‘Qotion 5; If your license staus is INACTIVE, you may elet not to obtain an NPI nner, Check the appropriste box below. supply appropriete information, and sig the bottoms of the page. HMvewennniis IMIS) FPA EeS 1D thave personally applied for an NPI. (You must Provide your NPI number to the Board wten received.) 1 t have applied for an NPI using a third pany (enter name}: ~ (follow nsrutions for Option 3) 1 By checking this option and signing the botiom of his page, thereby authorize the Board to apply for an NPI on my behalf. © Asan inactive physician, 1 do not wish to obtain an NPL HIPAA TAXONOMY CODES Please provide the HIPAA taxonomy (specialty) cedes (refer to enclosed Taxonomy Code Lis). In addition to providing the taxonomy code, please indicate your specilty inthe space provided (Taxonomy Description). The primary provider taxonomy code is required if you authorize BORIM to apply for en NPI on your behalf. Primary Provider Taxonomy: Provider Taxonomy: Wi H6b.- Ave, QDeense We NEA CRT, Cree Provider Taxonomy: {aa ongoing effort to improve the quality ofthe infarmation we collect, please review the following information aad make corrections as necessary. Please note: This information is required if you authorize BORIM to apply for an NPI on your behalf Social Seerity Number: Site of Binh F US) Coun or inh ouside he US) Gender: Male Femate uftne Information onthe Natonal Provider denier 18 U.S.C. 1001 authoriees eriminel penalties sgainst an individual who in any matter within the jurisdiction of any department or gency of ‘the United States knowingly and wilfully falsifics, conceals or covers up by any trick, scheme or device a meterial fast, or makes any false, fittious or fraudulent statements or representations, or makes any false wring or document knowing the same to contain any false, festious or fraudulent statement or entry. Inividuel offenders are subject to fines of upto $250,000 and imprisonment for upto five years. Offenders that are organizations ate subject to fines of yp to $500,000. 18 U.S.C. 3571(d) tls0 authorizes fines of up to twice the gross gain derived by the offender if is greater than the amount specifically authorized by the sentencing satu, Authorization for NPI 0 cascansh tantra goer Ps tenaton Me authorized hospital, health plan, or health organization. 1 to provide my NPI number to any Please sign and date to confirm-that all of the information os this form is true and xecurate, Dae: | 27Massachusetts Physician Renewal Application Physician Name: Jeffrey M Drazen, Mi PARTA 1) Current Status: Active Renewal Due Date: 04/21/2007 Birth Date: {Ifyou want to change your current status, please check one of the following boxes to indicste your naw status: Cheek only one: (See Renewal Insiructions, page 3.) O active D Retiring O inactive 1 Do not wish to renew License No: 36140 2) Addresses é Contact Information. Please confirm your addresses and make changes, if necessary. Vou 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 Bor. Please make corrections (print) 28) MAILING ADDRESS aeceneD ‘New England Jura of Medicine 10 Static Suet Boston, MA 02115 (Mailing Address: i Check here rochonge shi adress 2b) HOME ADDRESS ma Home Telephone: 1 Checker che sade Home address connot be a Past Office Bax 2) BUSINESS ADDRESS : New England Journal of Medicine eee 10 Shattuck Sweet Ciyrtown State: Boston, MA O2115 a caine me Business Telephone: (_), 1D Chek hereto chong hades Business address cannot be a Post Office Box Correct your E-mail and Fax Number below: 3) E-mail Address: 4) Fax Number; _617-739-9864 —— 5) Specialties (See Renewal Insiructions, page 4) Delce? List Additional Specialties: Pulmonary Diseases o “Critical Care Medicine o 0 ‘6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Iaformation. (Gee enclosed insructions and Renewal Insiructions, page 4) List Certifying Board(s) below: Update General Certificates and Subspecialty Certificates below. Please add additional Certifications as required. Boprd Name ABMS or Centtiente/Subspecialty Delete? Internal Medicine =__ABMS _ | Internal Medicine - Critical Cure Medicine a Internal Medicine ‘ABMS _ | lateral Medicine - Pulmonary Diseeses ojolo Page 1 of 9 »Massachusetts Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License No 36140 (See Renewal Insiructions, page 4) Please make corrections as necessary 1) Drug License Numbers Corrections: '8) Other states where you are now licensed to practice 8) Massachuseas: RV ECA eee eee ee eee ) Federal (DEA): 9) States where you were previously licensed ©) Federal (DEA) XS: = 20) List all work sites in Massachusetts, including health care facilities (where you are eredentialed), 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 auy affiliations with Internet-based prescribing services, or companies. Please provide all information on all work sites, attaching a separate sheet, if necessa tthe names af all work es Ta Mavatheses Tocailon sae See above and description on page 4) (chyor town) ‘Beth Israel Deaconess Medical Center Boston Medical Center Brigham & Women's Hospital Delete? ‘Childres’s Hospital Boston Dana Farber Cencer Instiute oO; oO} ojo\o 11) Care of patients in Massachusctts (See Renewal Insiructions, page 4) ‘Average weekly hours involved in: a) inpatient care 0 hesiwk Change to: outpatient care 9 hrslwk Change to: i 12) Medical Liability Insurance Information (aa Rencwal Insraclna, page 3) (Check one, Locum tenens mus lis policy des. My medial ibility insurance is provided Uwough: WF tnsurance Carrier (complete betow) (Curren Insurance Carrer: CRICO Changer: Policy dates: From 4/4/02 To 4k 134.07 Type of Policy: C1 Claims made wid tail coverage 0 Occurrence Policy (Enclose a copy of the certifieate of inswratiee or the face sheet) D Letter of Credit subject to Board approval (Amach a copy.) © 1am registering with Active stats but am not required to have medics ability Insurance bessose Iams Gheckont; (Not involved with director indirect patient care in Massechusetts _AGovemiment Employee under Federal Tort Claims Act (FTCA) O)Otherwise exempt (Please explain) 43) Do you perform any surgery in your Massachusetts office? (See Renewal Instructions, page S) Yes No If Yes, please complete Form PCA-O “Office Based Surgery” Form on page 8. Page 2 of 9; Massachusetts Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License Now: 36140 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 lastuctions, page 5.) You must check ether YES or NO to each question. Provide duals on Form, if you answer "YES" to any questions, Referto. Renewal Instructions for additional information and definitions YES NO eu 14) CLAIMS MADE a) NEW: Have you received notification ofa claim, whether or nota lawsuit was filed on that elim, or has any medical malpractice claim been made against you during this time period? (see above). b)PENDING: Are there any unresolved malpractice claims against you foday, i, any claims that have ‘ot been finaly settled or finaly adjudicated? 15) CLAIMS CLOSED ‘as any medical malpractice claim against you (whether or nota 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. 2) New: Have there been any claims, other than medical malpractice claims, filed against you during this time period? ') Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, uring this time period? 17) CRIMINAL CHARGES. 8) Have you been charged with any criminal offense during this time period? 'b) Have any criminal offensesicharges against you been resolved during this time period? ©) Are there any criminal charges pending against you todsy? 4) Are eny Applications for Issuance of Process pending against you? 18) INVESTIGATIONS AND DISCIPLINARY ACTIONS: ') Have you withdrawn an application to any governmental euthority, health care facility, group practice, ‘employer or professional association? ) 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 govemmental authority, health care foelity, group practice, employer or professional association? ‘) Have you been the subject ofa disciplinary ection taken by any governmental authority, health care facility, group practice, emplayer or professional association” 119) Have your privileges to possess, dispense or prescribe contolled substances been suspended, revoked, denied, resricied by, or surrendered to any state or federal agency? 720) Have you withdrawn an application for a medical license, allowed license application to become obsolete ‘or have you been denied a medical license for any reason? 721) Has any medical lability insurance carrier restricted, limited, erminated, imposed a sureharge or co-payment, or placed any condition related to proféssional competency or conduct on your coverage, or have you voluntarily restricted, fimited or terminated your insurance coverage in response to an inquiry by a medical liability insurance carrier? iI (33) CME CERTIFICATION: ‘) Have you completed your CME requirements preceding your renewal date? (&{/¥es[] No 1) no, ae you equstng CME waiver? Ove gNo ACCME waiver request form must be submited atleast 30 days rie to your cene expiration dat. €) you are exempt om CME requirement, chek eson fr exemption (Se Renowal Inaction, page 8) CME EXEMPTION: (eecone) Cl Inecive Sums Residency ellowstip wining Page 3 of 9Massachusetts Physician Renewal Application Physictan Name: Jeffrey M Drazen, M.D. License No: 36140 PART C a x PHYSICIAN PROFIL! ad 1 have reviewed my Physician Profile at hitov/prafles massmedboatd org and confirm that he information is accurate. (Please note tht if you changed or corrected your business addess, business phone number, practice specialty, board Ccentficetion and/or hospital afititions on your renewal application, your Physician Profie wil also be updsted.) © thave reviewed my Physician Profile and anached a copy ofthe Profle wih conection, (My satus is native and 4 not havea Physician Profile. See Renewel Inaction, poge Ul.) CERTIFICATIONS ions to report abuse or neglect of children pursuant to G.L. ¢. 119, see. 51A, and 1 1) certify that! have complied with my obl Understand the punishment for failure to comply. 2) | eenify that I have complied with my obligations to report abuse or neglect of disabled persons pursuant to G.L.€. 19C, see, 10, and ' understand the punishment for filure to comply. 3) leemify that have complied with my obligations to report abuse, neglect or financial exploitetion of elderly persons pursuant 10 GLL. c.19A, see. 15, and [understand the punishment for failure to comply. 4) certify that | have complied with my obligations co report the treatment of wounds, bums and other injuries pursuant to G.L.¢. 112, see. I2A, ') Leer that Ihave complied with my obligations to report the treatment of victims of rape or sexual asaul: pursuant to G.L. €. 112, see. 12A 1/2 8) leerify that | have complied with my obligations to report a physician to the Board of Medicine, pursuant to GL. ¢. 112, se. $F, ‘when Ihave a reasonable basis to believe that person violated any provisions of GL. c. 112, see. Sor any Board regulation, 7) Leenify that I have complied with my obligations related wo charging and collecting fees from Medicare beneficiaries in accordance ‘with the Medicare fee schedule, and I understand my obligations under G.L.e. 112, see. 2. 8) | cetfy that Ihave complied with my obligations to file Massachusets tax rtums and to pay Messachusets taxes, and ! undersiand {hat, pursuant to G.L. ¢.62C, see. 49A, my license shell not be issued or renewed unless I make these certifications under penahies of perjury. 9) |cenify that { have complied with my obligations related tothe eeporting of employees and contractors pursuant o G.L. 62E. 40) certify that I have complied with my obligations related tothe withholding and remitting of child support pursuant 10 G.L. ¢.L19A. 11) cenfy that | have complied with my obligations to file an Incident Report with the Board when cenein adverse events oscar in my private office, pursuant to G.L. c. 112 sec. $ and the Patient Care Assessment Reguletions, 243 C.M.R. 3.00 etzeg | understand that ‘the Patient Care Assessment (PCA) programs atthe health care facilities where {practice report certain Major Incidents to the Board. {2)1 cenify that 1 have complied with my obligations ta disclose my ownership incerest in any partnership, corporation, firm or other ‘egal entity to which I have ceferred a patient for physical therapy services pursuant to G.L.¢. 112, se IZAA. Under penalties of perjury, I declare that I have examined this renewal application and all its accompanying instructions, forms and statements, and f0 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. Signecur _-Date: 3 174) OF MAKE A CORY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. YOU MUST RETAIN A ‘COPY OF YOUR APPLICATION FOR YOUR RECORDS, FOR CREDENTIALING AND FOR OTHER PURPOSES. Page 5 of 9: Massachusetts Physician Renewal Application g Physician Name: Jetfrey M Dente, M.D. License No: 36140 § 5 NATIONAL PROVIDER IDENTIFIER (NPI) g ‘The primary purpose ofthe NPL is o uniquely identify health care providers as "health eae providers” in HIPAA. standard transections. | ‘The NPI will replace all other identifiers assigned to health care provider, such as those assigned by heck plans, government programs, and healthcare purchasers for purposes of conducting these business transactions, ™ ‘Under the finsl HIPAA NPI Rule, all individual and organization covered providers will be required to obtain an NPI by May 23, 2007 1m order for your license to be renewed you must take one ofthe following actions: Option 1: Supply the Board of Registration in Medicine with your valid NPI. You can apply for an NPI direcly by using the NPPES web site at ew 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 NP! Number, ‘yu rust ntify the Board, Pease compete the NPI form at the Board's web ste at wwav-meszmedboaréore. ‘Qation 3: Centify another authorized institution kas applied for an NPI on your behalf and you have noi received it yet (supply instnations name). Once you have received your NPI Number, you must notify the Board by competing the NPI frm the Board's website (see Option 2) ‘Option 4: Authorize the Board of Registration in Medicine to epply for an NPI on your behalf. ‘Opuion 5; If your license status is INACTIVE, you may elec roto obtain an NPI number, ‘Check the appropriate box below, supply appropriate information, and sign the bottom of the page. Awyarnnnis TA BIA i 1 ave personaly applied for an NPI. (You must prove your NPI number tothe Board when received.) 7 Ihave applied for an NPI using 2 (follow instructions for Option 3) By checking this option and signing the bottom of this page hereby authorize the Board to pply for an NPI on my behal. T Asem inactive physician, | do not wish vo obtain an NPI HIPAA TAXONOMY CODES Please provide the HIPAA taxonomy (specialty) codes (refer to Renewal Instructions, page 2! for more information). In addition to providing the taxonomy code, please indicate your specialty in the space provided (Taxonomy Description). The primary provider taxonomy code i required if you authorize BORIM to apply fran NPI on your behalf Primary Provider Taxonomy: we tes.- doenadaey ds. Provider Taxonomy: QC) Arhee- Caran. Chee Provider Taxonomy’ a In an ongoing effort to improve the quality of the information we collect, please review the following information and make corrections as necessary. Please note: This information is gequted if you authorize BORIM to apply for an NPI on your behalf. AESSOVAL Contry of Bink (ifouside the US): D Female es for Faleving informa lon F Heaton 18USC. 1001 authorizes criminal penalties agaist an indiviual who in any mater wii he jurisdiction of any deprtmentorageney of ‘the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false, fctkious or eadulentsatenents or represetionsor makes any fle wing or docimentKaowing the Same to contain ay false, feitius or fauduentsttemert or ent. Indvidulefenders are sujet to fines of up to $250.00 td imprisonment for pt ie yea. Offenders that are organizations are subject o fins of upto $50,000.18 U.S.C 3571) also autharies fins of up to twice the gos gain ‘erved bythe offender iis preser han the mount specfaly authorized bythe senteecing saute ‘Authorization for NPE Dissemination 11 authorize CI 1 donot authorize the Board of Registration in Medicine to provide my NPL number to any authorize hospital, health plan, oF health organtzation. Please sign and date wo confirm that all ofthe information on thi form i true and accurate. Signature: Dae: J (46107 Page 7 of 9Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jetivey M Drazen, M.D. License No.: 36140 Current Status: Active 1) Activity Status: Active 2) Address & Contact Information Mailing Address: New England Journal of Medicine 10 Shatluck Sireet Boston Massachusetts -02115 United States of America Home Address: Business Address: New England Journal of Medicine 40 Shatluck Sireet Boston Massachusetts . 02115 United States of America (617) 487-8570 2) Email Address: 4) Fax Number: (617) 739-9864 5) Specialties Cirtical Care Medicine Pulmonary Disease 8) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) format 7 ABMSIAOA Board Name Certification Subspeciat ASMS Internal Mec cine Interal Medicine Gitta Care Ytecicine ABMS Internal Mesicine Internal Medicine Pumonary Diseases, 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 5) Other states where you ae now licensed to practice orn NewYork 9) States where you were previously licensed None Reported” “re Previously 10) Work sites st of all work sites in Massachusetts, including health care faciities (where you are credentialed), private office, clinics, nursing hames, etc Paget ofS ate: sarisCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License No.: 36140 Worksite Location Beth israel Deaconess Medical Center Boston Boston Mecical Center Sosion Brigham & Women's Hospital Boston Children's Hospital Boston Boston Dana Farber Cancer Intute Boston 11) Gare of patients in Massachusetts ‘Average weekly hours involved in: a) inpatient care 0 hrswk ) outpatient care 0 hrsivk 12) Medical Liability Insurance Information Insurance Carier Policy Start Date PolicyEnd Date Policy Type Controlled Risk Insurance Company of Verm 01/01/2011 1281/2011 Occurrence Policy 18) Do you perform any surgery in your Massachusetts office? 14) Claims Made 18) New: Have you received notification of a clam, whether or not a lawsut was filed on that claim, or has ‘any mecical malpractive claim been made against you duting this tme period” b) Pending: Are there any unrescived malpractice claims against You today, Le., any claims that have not been resolved, settled or aqjucicsted during this time period? 18) Claims Closed Has any medical malpractice claim against you (whether or not a lawsuit was fied on that claim) been resolved, settled, of adjudicated during this time petiod? 16) Other Civil Lawsuits ‘Question 16 refers to claims or actions related lo your competency to practice mecicine or your professional conduct in the practice of medicine, 4) New: Have there been any claims, other than medical malpractice claims, flied against you during this ime period? p) Rescived: Have you resolved, settied or adjudicated ary lawsuits, other than medical malpractice claims, during this period? 17) Criminal Charges 3 ‘Have you been charged with any criminal offense during this period? b) Have any criminal offenses/charges against you been resolved during this time peri 6) Are there any criminal charges pending ageirist you today’? 4) Are any Application of lasuance of Process pending against you? 18) Omer ssues 2) Have you witrawn an application lo any governmental authotty, heath care fecly, group prectice employe cr professional association? t) Have you eve taken a lezve of absence from any health cae tality, @oup prectice or employer? «} Have you been the subject ofan irwestigaton by any goveinmenial cork, nealn care Toy, group Feel, employee proesstona! asgoiion? ca lave you ben the scien of» ciscisinary ation tken by ar goverreertal auhorty, neath care ‘acy, gouppracic, empoyer of professionel association? 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, ”fevoke, dani, resid by oy suandted ke any seas oy tas ares i 20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete or have you been denied a medical license for any reason? Page 2015 Date: sa0v4Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Nama: Jetirey M Drazen, M.D. License No.: 36140 21) Has any medica! 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 te an inquity by a medical liability Insurance carrier? 22) Have you completed all CME requirements (100 hours of CME of which 10 hours must be in risk management Requirement: 40 hours credit n Category 1 and 80 hours im Category 2) for this Yes renewal period? (if you ai roved Residency! Fellowship program, or lf your are. renewing your license for the first time, please answer Yes) Pagedots Date: snaroit Tina: 5:19 PMCommonweaith of Massachusetts Board of Registration in Medicine Physician Renewal Application Jeffrey M Drazen, M.O, License No.: 36140 have a medical condition that interferes in any way or limits your ability to practice 24) Have you used any chemical substance(s) which in any way interferes with your ability to Practice medicine? Paged ofS Date: star014 Time: 5:19 PMcae Massachusetts Physician Renewal Application {List Certying Board) below Update Generl Ceriices and Subapedaliy Cerin : below. Please add addons! CerMatons as required. k Bonit Niiné* ABMS or AOA| Certificate/Subspecialty . x » [nena ec” ‘ABMS | ltersal Medicine - rial Cle Mesice Intemal Medicine’ ~ ABMS Interna} Medicine - Pulmonary Diséascs Phytlelan Name: Jeffrey M Drazen, M.D. License No 36140. PARTA +/.1) Carvent Status: Active Renewal Due Date: 04/21/2009 Birth Date: Af you want to change your current stas, plesse check one ofthe following boxes to indicate your naw status: pec ony oe (Gee Renewel Instructions, page 3.) . Active 1 Retiring O inactive O Do not wish to renew 2) Addresses & Contact Informaation. Please confirm your addresses and make chauges, If necessary. You are required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and ‘Business addresses CANNOT be a Post Office Box. Please make corrections (print) 2a) MAILING ADDRESS ee | New Enjland Journal of Medicine Mailing A 10 Shattuck Street Boston, MA 02115 CiyrTown: Stee: Zip. Country: 1 Oiee bere change ieee eee 2b) HOME ADDRESS Weave ames eeceescee CityTown: Suate: ig County: i hone: pee WAR 24 709 jome Telephone: ( aut 1 ct bere chong is, Home address cannot bea Post Office Box i Boartot Registration. "A cont no Pen Oe YC ch bbe : Business address cannol be a Post Office Box ‘Correct your E-mail and Fax Number below: 3) E-mall Address 4) Fax Number: _ 617-739-9864 5) Specialties (See Renewal Insiructons, poge 4) Deets? | List Additional Specalics: ‘Pulmonary Diseases o (ls ical Care Medicine o Ee o ©) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) laformation. (ee enclosed instructions and Renewal Instructions, page 4.) Page 1 of 7 os oUscren crMassachusetts Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License No 36160 (Gee Renewal inractions, page €) "Please make corrections as necessary *| 7) DragLicense Numbers Corrections: 4) Other states where you are nom licensed to practice 1) Massochusene: bose eae vee eee eee ') Federal (DEA): 9) States where you were previously eensed ¢) Federal (DEA) XS: : 10) List sll work sites in Massachusetts, including health care facilities (where you are credentialed), private offices, clinies, nursing homes, etc. For the names of the health care facilities, refer to Reference Table 4 00 age 18 of the Renewal Instruction 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. (Fiske namics of al work lies Tn Masachuveris Toeation Tiare (See above and description on page 4.) (City or Town) | Beth reel Deaconess Medical Center Bosrow | HA_| Bosto Medical Center . “ et Brigham & Women's Hospital 5 «| Chien Hospi Boxon 7 ~_ tI Dana Farber Cancer Institute a 7 ” TH) Care of patients in Massachuets Seg Renewal Istrucions page @) Average weekly hours involved in: ») inpatient care 2 hew/wk © Change to: __._ra/wk Dyoupatent cue © trv Change to: ve | 132) Medical Liability Insurance Information (See Renewal Iniractions, page 5) Check one. Locum teneas mus list poly detes. My medical liability insurance is provided through: Insurance Carrier (complete below) (Current Insurance Carrier: CRICO Change to: Policy dates: From / 14 [8009 To Ak /8/ /0O9 ‘Type of Policy: ©) Claims made with wil coverage Gi Occurrence Policy ‘(Enclose copy ofthe certileate of insurance or the face sheet) O Letter of Credic: beet to Board approval (Anach a copy.) o ‘Jam registering with Active status but 1 am not required (o have medical liability insurance because I am: ‘Sreck.one; C1 Not involved with diet or indirect patient car in Macsachuset. (A Goverment Enployee under Federal Tort Claims Act (FTCA) C1 Otherwise exempt Please explain): 13) Do you perform any surgery in your Massachosetts office? (Sen Renewal Instructions, page) Yes No IF Yes, please complete Form PCA-O "Office Based Surgery” Form on page 8. Page 2of7 eS corserenE Massachusetts Physician Renewal Application Physicen Name: Jefirey M Drazen, M.D. License No 36140 In questions 14-21, the phrase "time period” refers to the following ~ all time from the day you signed your last | Mcense Renewal Application to the day you sign this Renewal Application, (See Renewal Instructions, page 8) ‘ You miust cbeck either YES or NO to each question. Provide details on EoumR if you answer "YES" to any questions. Refer to . Renewal Instructions for additional information and definitions. YES NO 14) CLAIMS MADE 2) NEW: Have you received notification of claim, whether or nt Iawauit was fled om tat claim, or tas any medical malpractice ckim beco nde against you ducing thi me period? (see above). Db) PENDING: Are there any unresolved malpractice cleims against you today, ic, any claims that have ot been Ginaly setled or Finally adjudicated? 15) CLAIMS CLOSED Hs any medical malpractice claim against you (whethcr or not e lawsuit was fled on that claim) been resolved, setled, oF adjudicated during this ime period? 16) OTHER CIVIL LAWSUITS (Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct inthe practice of medicine. 4) New: Have there been any claims, other than medical malpractice clas, filed against you during this time period? Resolved: Have you resolved, etied or adjudiceted any Inwavit, 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’? "_b) Have any criminal offenses/charges against you been resolved during ths time period? ©) Are there aay criminal charges pending against you today? <) Are exy Applications for Issuance of Process pending eguinst you? 118) INVESTIGATIONS AND DISCIPLINARY ACTIONS + | ©) Have you withdrawn an application to any governmental authcrity health ear facility, group practice, ‘employer or professional association? ») Have you ever taken a leave of absence from any healthcare 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? 4) Have you been the subject of a disciplinary action wken by any governmental autbority, health care facility, group practice, employer or professional association? 19) Have your privileges 1o possess, dispense or prescribe controlled substances been suspended, revoked, cnied, resticted by, or surrendered to any sate br federal agency? | | ortave you been denied a medical license for any reason? 21) Has any medica! lability insurance carer restricted, limited, terainated, imposed o surcharge or ‘co-payment, or placed aay condition seisted to professional competency or conduct on your coverage, oF have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquizy by 20) Have you withdrawn an epplication fore medical liceage, ellowed » license application w become cbeolee ‘ACME waiver request form must be subsuitted at Jeatt 30 daye prior to your license expiration date. CME EXEMPTION: (check one) CI Inactive Status). Residency/Fellowship taining Page 3 of 7 + medical lability insurance earcier? [Bay CME CERTIFICATION: 12) Have you comple your CME reqrements preceding yourreneval dae? Eee] No Dy fno, are you requesting 8 CME waiver? Der Ne ©) If jou are exempt from CME requiresnents, check reason for exemption. (See Renewal Instructions, page 8.) os DorEreD BisCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License No.: 36140 Current Status: Active License Expiration Oate: 5/19/2013 1) Activity Status: Active 2) Address & Contact Information Malling Address: New England Journal of Medicine 10 Shatiuck Sireet Boston Massachusetts - 02115 United States of America Home Address: Business Address: ‘New England Journal of Medicine 10 Shattuck Sireet Boston Massachusetts - 02115, United States of America (617) 487-6570 3) Email Address: 4) Fax Number: (617) 739-9864 8) Speciattios Citical Care Medicine Pulmonary Disease 8) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMSIAOA Board Name Certification ‘Subspecial ABMS Internal Medicine Internal Medicine Grtical Care Medicine ABMS Internal Medicine Internal Medicine Pulmonary Diseases. 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice California 9) States where you were previously licensed New York bas . ad 10) Work Sites Ust ofall work sites in Massachusets, inclucing health care facilities (where you are credentialed), private ‘office, elinios, nursing homes, ete, Worksite Location Beth israel Deaconess Medical Center Boston Paget ot Date: sn47033 Tne: 4:51 PmCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License No.: 36140 Boston Medical Center Boston Brigham & Women's Hospital Boston Children’s Hospital Bost Boston Dana Farber Cancer Institute Boston, 11) Gare of patients in Massachusetts ‘Average weekly hours involved in: a) inpatient care 0 hsiwk ) outpatient care 1 hrstivk 12) Medical Liability insurance Information Insurance Carrier Policy Start Date PolicyEnd Date Policy Type Controlled Risk insurance Company of Verm01/1/2013 1281/2013 Claims mace with tal coverage 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made a) New: Have you received notification of a claim, whether or not a lawsuit was filed on that claim, or has any mecical malpractice claim been made against you during ths time period? ') Pending: Are there any unresolved malpractice claims agains! you today, .0,, any claims that have not been resolved, settled or acjucicated during this tme period? 16) Claims Closed Has any medical malpractice claim against you (whether or not a lawsult was filed on that claim) been Fesolves, settied, or adjudicated during this time period? 16) Other Clit Lawsutts Question 76 refers to clsims or actions related to your competency to practice medicine or your brofessionel conduct in the practice of medicine. 8) New: Have tere been any claims, other than medical malpractice claims, fied against you duting this ime perio ») Resolved: Have you resolved, settied or acjucicated ary lawsuits, cher than medical malpractice ‘claims, during this period? 17) Criminal Charges 2} fave you been charged wih any criminal offense curing this period? 2) Have any criminal offenses/charges against you been resolved during this time petiod? {) Are there any ermival charges pending against you today? 4) Are any Application of Issuance of Process pending against you? 18) Other Issues 2) Have you withdrawn an appication o any governmental authority, heatth care fecity, group practice ‘employer or professional association? fiave You ever ake 2eave of aberce rom ay hea cae faci, group practice or employer? 6) eve you been the subject of an irvestgaon by any gavemnmerial shorty, icing ie Massachusetts Board of Registration in Medicine r ary other siate medica! board. heath care faciy, group practice, employer or professional association? ©) Have you been the subject ofa dscipinary action taken by any governmental authoriy, health care "a group poco, aslo: opleduons aeesen 18) Have your privileges to possess, dispense or prescribe controlled substances been suspended, Fevoked, denied, restricted by or surrendered to any state of 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? Pago2ot$ 1: 472013Commonwealth of Massachusetts @® Board of Registration in Medicine Physician Renewal Application Physician Name: Jetfrey M Drazen, M.D. License No.: 36140 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge of co-payment, or placed any condition related to professional competeticy or conduct on your Seuciage, or have you voluntarily restricted, limited or terminated your insurance coverage in response'to an inquiry by a medical liability insurance carrler? 22) Have you completed all CPO requirements (100 hours of CPD of which 10 hours must be in risk reneve pened’ tweet 40 hours cregitin Category 1 and 60 outs In Category 2) for this reneuancatiod{ifyou are in an approved Residenty! Fellowship program, or # your are renewing your licenise for the first time, please answer Yes) Yes Dare: sn42019 Tame: 4:54 PMCommonwealth of Massachusetts Board ot tegstatonn are Physician Renewal Application Physician Name: Jetiey M Drazen, M.O. License No. 36140 22) Do you have a medical condition that interferes in any way of limits your ability to practice » medicine? ¥ peaeeceaat 24) Have you used any chemical substance(s) which in any way interferes with your ability to ” Pract maciciney nem ae ee a Pope ots Dae: 3142019 Tima: 454 PaCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jetfrey M Drazen, M.O. License No.: 36140 Current Status: Active License Expiration Date: §719/2015 1) Activity Status: Active 2) Address & Contact Information Mailing Address: New England Journal of Medicine 410 Shalluck Street Boston Massachusetts - 02115 United States of America Home Address: Business Address: New England Journal of Medicine 10 Shatluck Street Boston Massachusetts - 02115 United States of America (617) 487-6570 3) Email Address: 4) Fax Number: (617) 739-9864 5) Speciaities Citical Care Medicine Pulmonary Disease 6) Current American Board of Medical Specialties (ABMS) or American Osteopathle Association (AOA) formation ABMS/AOA Board Name Certification Subspecaty, ‘ABMS Internal Mecicine Internal Medicine Giitical Care Mecicine ABMS Internal Mecicine Internal Medicine Pulmonsry Diseases 7) Drug License Numbers Massachusetts. Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice Calltornia 9) States where you were previously licensed New York 10) Work Sites LUst of all worksites in Massachusetts, including health care fclities (where you are credentialed), private office, clini, nursing homes, ete Worksite Location Beth Israel Deaconess Mecical Center Boson Pages of s Date: an201s Time: 1:59 PmCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jeffrey M Drazen, M.D. License No.: 36140 Boston Medical Center Boston Brigham & Women's Hospital Boston Chilcren’s Hospital Boston Boston Oana Farber Cancer Institute Boston 14) Care of patients in Massachusetts ‘Average weekly hours involved in: a) inpatient care O hrs/wk ) outpatient care 1 hrsivk 12) Medical Liability insurance Information Insurance Carrier Policy Start Date Policy End Date Pelicy Type Controlled Risk insurance Company of Verrn0V01/2015 1213172015 (Claims made with tail coverage 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made 2) New: Have you received notification of s claim, whether or not 2 lawsuit was filed on thal claim, or ‘any medical malpractice claim been made against you during this lime period?” b) Pending: Are there any unresolved malpractice claims against you today, ie, any claims thal have not ‘been resolved, Settled or adjudicated during this time penioc? 16) Claims Closed Has any mecical malpractice claim against you (whether or not a lawsuit was fled on that claim) been resolved, settied, or adjudicated during this time period”? 16) Other Civil Lawsults ‘| ‘Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 2) New. Have tere been ary claims, other than mevical malpractice claims, filed against you during this ime peri b) Resolved: Have you resolved, settled or adjucicated ary lawsuits, other than medical malpractice claims, during this period? 47) Criminal Charges 2) Have you been charged with ary cirinel ofense during this period? b) Have any criminal offensesicharges against you been resolved during this time period? {) Are there ary criminal charges pending against you today? 9) Are any Application of Issuance of Process pending against you? 18) Other Issues: 8) Have you withdrawn an application to any governmental authoriy, health cate fecitty, group practice employer or professional association? ®) Have youtaken a eave ol absence rom any heal care facity, etouppracce or employer for reasons related to your competence to practice medicine? ©) Have you been the subject of an investigation by any governmental authorty, including the Massachusetts Board of Registration in Medicine or any other state medical board, health care Facility, fouP practice, employer o professional association’? ) Rave you been the subject ofa disciplinary action taken by any govemmental authority, health care faclity, group practice, empioyer or professional association? 19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, )Fevokea, denna Fosiicled by or Surfandera fo ay ses ot a ea - lowed a license application to for any reason? 20) Have you withdrawn an application for a medical license, become obsolete or have you been denied a medical lice’ ‘ma: 4:53 PR PagezetsCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jettey M Drazen, M.D License No.: 36140 24) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge 9F co-payment, of placed any condition related to professional competency ot conduct on your coverage, or have you voluntarily restricted, limted or terminated your insurance coverage in response to an Inquiry by a medical liability insurance carrier? 2) Have you competed all of the CPD requirements for this renewal cycle? i you are renewing your license for the first time or participating in postgraduate training, please answer Yes. Yes Page aot: ote: snr2018 Time: 1:59 PltCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Jeffey M Drazen, MO 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 abllity to practice medicine’ Page dot Date: sn7r2015 Tio: 1:53 Pk