Fillable Printable Quarterly Declaration - California

Quarterly Declaration - California

BUSINESS, CONSUMER SERVI CES, AND HOUS I NG AGENCY - D epartment of Consumer Affairs EDMUND G. BROWN JR., Governor

M EDICAL BOARD OF CALIFORNIA

Refer to www.mbc.ca.gov for office locations

Quarterl y Decl aration

INSTRUCTIONS: Please type or print neatly. ALL requested information and questions on this form must be answered. When space

provided i s ins uf fi cie nt, att a ch addit ion al sheets of p aper . All attachme nts are con sid ered part of th e Declarati on. You ma y w ish to make

and retain a copy of the m aterial subm itted to t he Medical Board. Mail the complete d Declaration to your assigned pr obatio n monitor. DO

NOT FAX your Declaration. The Medical Board requires an original signature on each quarterly declaration and a faxed signature will

not be accepted.

Check Appropriat e Box for Reporting Period Covered

Reporting Period Due to the Board By

 January - March (First Quarter) April 10

 April - June (Second Quarter) July 10

 July - Sept em ber (Third Quart er) Oct ober 10

 October - December (Fourth Quarter) January 10

(Continued on reverse)

Name: First Middle Last Aliases

Home Address: Nu mber & Street City State Zip Phone Number

( )

Primary Place of Practi ce (i nclude additi onal plac es of practice on reverse)

Address: Number & Street City State Zip P hone Num ber

( )

E-mail Address:

Work ________________________________________________

Personal

Cell Phone Num ber

( )

Indicate the number of hours worked this quarter at your primary place of

practice:

P er week Per month

What is your work schedule at this place of prac tice?

The Following Questions Refer to t he Time Period Si nce

Your Last Quarterly De cl ar ation

1. Have you violated any count y or city ordinances, been arrested, charged, convicted of, pled nolo

cont endere in any state or federal court or foreign count ry to any misdemeanor, f el ony, or other offense?

(If yes, specify which one in your explanation. E xclude parking tickets.)

2. Have you violated, been arrest ed, convicted of, or received a citation for driving under the influence of

alcohol or drugs, reckless driving, or any ot her vehicle code violation involving alc ohol or drugs?

3. Are you required to undergo biological fluid testing by any directive other than what is in your

Order? If yes, when were you last tested and what is the frequenc y of testing?

4. Is there any governmental, civil suit, malpractice, or peer review pr oceeding pending against

you?

5. Have you resigned from any employment or has your em pl oym ent been terminated?

6. Are you in the process of applying for any other business or profess i onal licens e or

certificate?

7. Have you had to report any theft or loss of controlled substances to the Department of

Justice?

8. Have you had to report a patient death in an outpatient surgery setting pursuant to Business

and Profess i ons Code secti on 2240(a)?

9. Did you cease practici ng since your last report? If yes, give t he date you ceased practice.

 Yes*  No

(Continued)

10. Have you been denied, had a lic ense or certificate to practice a business or profession suspended,

revoked, or surrendered or otherwise disciplined by any other federal, state, government agency or other

country?

11. Have you m ai ntained a current and valid lic ens e?

12. Are you c urrent with your probation monitoring costs?

13. Have you compl i ed with each term and conditi on of your probati on?

 Yes*  No

 Yes  No*

*IF YOU ANSWERED YES, to the above quest ion numbers 1 through 10 or N O to question

numbers 11 through 13, you must explain in det ail on an attached sheet of paper.

List the name, address, and work schedule (hours/days) of any other locatio n s where you practice medi cine (i. e., convalescen t /

nursing homes, etc. Provide the phone number of the Medical Director or Chief of Staff, if applicable.

Provide the titles of continuing edu cati o n cour ses you have completed for this quarter, if an y. Attach a copy of the CME certificate.

Do you p ractice any type of specialty? If yes, pl ease describ e which specialty.

List any new staff and include their ti tle and license number, if applicable.

What question(s), if any, do you have for your probation monitor regarding your probation.

Executed on __________________________, 20_____, at _______________________________, _________

City State

I hereby submit this Quarterly Declaration as required by the Medical Board of California and its Order of

probation thereof and declare under penalty of perjury under the laws of the State of California that I have

read the foregoing declaration and any attachments in their entirety and know their contents and that all

statements made are true in every respect and I understand and acknowledge that any misstatements,

misrepresentations, or omissions of material fact may be cause for further disciplinary action.

Probationer (print name) Signature

PRO-15 (Revised 3/2015)