TITLE 22. EXAMINING BOARDS

PART 9. TEXAS MEDICAL BOARD

CHAPTER 172. TEMPORARY AND LIMITED LICENSES

SUBCHAPTER C. LIMITED LICENSES

22 TAC §172.19

The Texas Medical Board (Board) adopts new §172.19, concerning Sports Team Physician Limited License, without changes to the proposed text as published in the March 23, 2018, issue of the Texas Register (43 TexReg 1792) and will not be republished.

The new rule applies to out-of-state, non-Texas licensed physicians who are designated or employed as a physician for visiting athletes, athletic teams, sporting-event related individuals participating in sporting events in Texas, and family members of such individuals. The new rule creates an exemption from Texas medical licensure requirements for visiting team physicians who are licensed to practice medicine in the team's home state and who limit care to the team's members, coaches, staff, and family members of such individuals during sporting events held in Texas that last no longer than 21 consecutive days. The new rule will also require a limited license for sporting events that last longer than 21 consecutive days. The rule is being adopted in accordance with the Sunset Advisory Commission's management direction (Staff Report, Final Results, August 2017).

The Board sought stakeholder input through the Licensure Stakeholder Group, which made comments on the suggested changes to the rules that were incorporated in the proposed text.

The Board received a written comment from the Texas Orthopaedic Society in support of the rule. The Board received no other written comments

The new rule is adopted under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure. The rule is also proposed under the authority of Texas Occupations Code Annotated, Chapter 155.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 28, 2018.

TRD-201802857

Stephen "Brint" Carlton, J.D.

Executive Director

Texas Medical Board

Effective date: July 18, 2018

Proposal publication date: March 23, 2018

For further information, please call: (512) 305-7016


CHAPTER 185. PHYSICIAN ASSISTANTS

22 TAC §§185.4, 185.6, 185.8, 185.14, 185.17, 185.31

The Texas Medical Board, on behalf of the Texas Physician Assistant Board (Board) adopts amendments to §§185.6, 185.8, 185.14, 185.17, and 185.31, concerning Physician Assistants, without changes to the proposed text as published in the February 2, 2018, issue of the Texas Register (43 TexReg 533) and will not be republished. Section 185.4 is adopted with changes to the proposed text as published in the February 2, 2018, issue of the Texas Register (43 TexReg 533). Section 185.4 is adopted with a minor grammatical change. The word "and" is removed at the end of subsection (a)(8), and the section will be republished.

The amendments to §185.4, concerning Procedural Rules for Licensure Applicants, eliminate the requirement for applicants to have good moral character and add language requiring applicants to submit to a criminal background check. These changes are based on the passage of SB 1625 (85th Regular Session), which amended §204.153 and §204.1525 of the Physician Assistant Licensing Act. The proposed amendments also eliminate obsolete language referring to "surgeon assistants."

The amendments to §185.6, concerning Annual Renewal of License, change registration of physician assistants to biennial instead of annual. The proposed changes also add language to require applicants to submit to a criminal background check. Finally, the proposed rule changes include new language providing that the Board may refuse to renew a license if the licensee is not in compliance with a Board Order. These changes are based on the passage of SB 1625 (85th Regular Session), which amended §§204.1525, 204.156 and 204.158 of the Physician Assistant Licensing Act.

The amendments to §185.8, concerning Inactive License, change the reference from "annual" registration to "biennial" registration. These changes are based on the passage of SB 1625 (85th Regular Session), which amended §204.156 of the Physician Assistant Licensing Act.

The amendments to §185.14, concerning Physician Supervision, change the reference from "annual" registration to "biennial" registration. These changes are based on the passage of SB 1625 (85th Regular Session), which amended §204.156 of the Physician Assistant Licensing Act.

The amendments to §185.17, concerning Grounds for Denial of Licensure and for Disciplinary Action, add language that provides the Board may refuse to renew a license if the licensee is not in compliance with a Board Order. These changes are based on the passage of SB 1625 (85th Regular Session), which amended §204.158 of the Physician Assistant Licensing Act.

The amendments to §185.31, concerning Prescriptive Authority Agreements: Minimum Requirements, delete language requiring face to face meetings as part of quality assurance and improvement plans. These changes are based on the passage of SB 1625 (85th Regular Session), which amended §157.0512 of the Medical Practice Act.

No comments were received regarding adoption of the rules.

The amendments are adopted under the authority of the Texas Occupations Code Annotated, §204.101, which provides authority for the Board to recommend and adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; enforce this subtitle; and establish rules related to licensure. The rules are further adopted under the authority of Texas Occupations Code §601.254.

§185.4.Procedural Rules for Licensure Applicants.

(a) Except as otherwise provided in this section, an individual shall be licensed by the board before the individual may function as a physician assistant. A license shall be granted to an applicant who:

(1) submits an application on forms approved by the board;

(2) pays the appropriate application fee as prescribed by the board;

(3) has successfully completed an educational program for physician assistants accredited by the Accreditation Review Commission on Education for the Physician Assistant, Inc. (ARC-PA), or by that committee's predecessor or successor entities, and holds a valid and current certificate issued by the National Commission on Certification of Physician Assistants ("NCCPA");

(4) certifies that the applicant is mentally and physically able to function safely as a physician assistant;

(5) does not have a license, certification, or registration as a physician assistant in this state or from any other licensing authority that is currently revoked or on suspension or the applicant is not subject to probation or other disciplinary action for cause resulting from the applicant's acts as a physician assistant, unless the board takes that fact into consideration in determining whether to issue the license;

(6) is of good professional character as defined under §185.2(8) of this title (relating to Definitions);

(7) submits to the board any other information the board considers necessary to evaluate the applicant's qualifications;

(8) meets any other requirement established by rules adopted by the board;

(9) must pass the national licensing examination required for NCCPA certification within no more than six attempts; and

(10) must pass the jurisprudence examination ("JP exam"), which shall be conducted on the licensing requirements and other laws, rules, or regulations applicable to the physician assistant profession in this state. The jurisprudence examination shall be developed and administered as follows:

(A) The staff of the Medical Board shall prepare questions for the JP exam and provide a facility by which applicants can take the examination.

(B) Applicants must pass the JP exam with a score of 75 or better within three attempts.

(C) An examinee shall not be permitted to bring medical books, compends, notes, medical journals, calculators or other help into the examination room, nor be allowed to communicate by word or sign with another examinee while the examination is in progress without permission of the presiding examiner, nor be allowed to leave the examination room except when so permitted by the presiding examiner.

(D) Irregularities during an examination such as giving or obtaining unauthorized information or aid as evidenced by observation or subsequent statistical analysis of answer sheets, shall be sufficient cause to terminate an applicant's participation in an examination, invalidate the applicant's examination results, or take other appropriate action.

(E) An applicant who is unable to pass the JP exam within three attempts must appear before a committee of the board to address the applicant's inability to pass the examination and to re-evaluate the applicant's eligibility for licensure. It is at the discretion of the committee to allow an applicant additional attempts to take the JP exam.

(F) A person who has passed the JP Exam shall not be required to retake the Exam for relicensure, except as a specific requirement of the board as part of an agreed order.

(b) The following documentation shall be submitted as a part of the licensure process:

(1) Name Change. Any applicant who submits documentation showing a name other than the name under which the applicant has applied must present certified copies of marriage licenses, divorce decrees, or court orders stating the name change. In cases where the applicant's name has been changed by naturalization the applicant should send the original naturalization certificate by certified mail to the board for inspection.

(2) Certification. Each applicant for licensure must submit:

(A) a letter of verification of current NCCPA certification sent directly from NCCPA, and

(B) a certificate of successful completion of an educational program submitted directly from the program on a form provided by the board.

(3) Examination Scores. Each applicant for licensure must have a certified transcript of grades submitted directly from the appropriate testing service to the board for all examinations accepted by the board for licensure.

(4) Verification from other states. On request of board staff, an applicant must have any state, in which he or she has ever been licensed as any type of healthcare provider regardless of the current status of the license, submit to the board a letter verifying the status of the license and a description of any sanctions or pending disciplinary matters. The information must be sent directly from the state licensing entities.

(5) Arrest Records. If an applicant has ever been arrested, a copy of the arrest and arrest disposition needs to be requested from the arresting authority and that authority must submit copies directly to the board.

(6) Malpractice. If an applicant has ever been named in a malpractice claim filed with any liability carrier or if an applicant has ever been named in a malpractice suit, the applicant must:

(A) have each liability carrier complete a form furnished by this board regarding each claim filed against the applicant's insurance;

(B) for each claim that becomes a malpractice suit, have the attorney representing the applicant in each suit submit a letter directly to the board explaining the allegation, dates of the allegation, and current status of the suit. If the suit has been closed, the attorney must state the disposition of the suit, and if any money was paid, the amount of the settlement. The letter shall be accompanied by supporting documentation including court records, if applicable. If such letter is not available, the applicant will be required to furnish a notarized affidavit explaining why this letter cannot be provided; and

(C) provide a statement, composed by the applicant, explaining the circumstances pertaining to patient care in defense of the allegations.

(7) provide a complete and legible set of fingerprints, on a form prescribed by the board, to the board or to the Department of Public Safety for the purpose of obtaining criminal history record information from the Department of Public Safety and the Federal Bureau of Investigation;

(8) Additional Documentation. Additional documentation as is deemed necessary to facilitate the investigation of any application for licensure must be submitted.

(c) All physician assistant applicants shall provide sufficient documentation to the board that the applicant has, on a full-time basis, actively practiced as a physician assistant, has been a student at an acceptable approved physician assistant program, or has been on the active teaching faculty of an acceptable approved physician assistant program, within either of the last two years preceding receipt of an application for licensure. The term "full-time basis," for purposes of this section, shall mean at least 20 hours per week for 40 weeks duration during a given year. Applicants who are unable to demonstrate active practice on a full time basis may, in the discretion of the board, be eligible for an unrestricted license or a restricted license subject to one or more of the following conditions or restrictions as set forth in paragraphs (1) - (4) of this subsection:

(1) completion of specified continuing medical education hours approved for Category 1 credits by a CME sponsor approved by the American Academy of Physician Assistants;

(2) limitation and/or exclusion of the practice of the applicant to specified activities of the practice as a physician assistant;

(3) remedial education; and

(4) such other remedial or restrictive conditions or requirements which, in the discretion of the board are necessary to ensure protection of the public and minimal competency of the applicant to safely practice as a physician assistant.

(d) The executive director shall report to the board the names of all applicants determined to be ineligible for licensure, together with the reasons for each recommendation. An applicant deemed ineligible for licensure by the executive director may within 20 days of receipt of such notice request a review of the executive director's recommendation by a committee of the board, to be conducted in accordance with §187.13 of this title (relating to Informal Board Proceedings Relating to Licensure Eligibility), and the executive director may refer any application to said committee for a recommendation concerning eligibility. If the committee finds the applicant ineligible for licensure, such recommendation, together with the reasons therefore, shall be submitted to the board. The applicant shall be notified of the panel or committee's determination and given the option to appeal the determination of ineligibility to the State Office of Administrative Hearings (SOAH) or accept the determination of ineligibility. An applicant has 20 days from the date the applicant receives notice of the board's determination of ineligibility to submit a written response to the board indicating one of those two options. If the applicant does not within 20 days of receipt of such notice submit a response either accepting the determination of ineligibility or providing notice of his or her intent to appeal the determination of ineligibility, the lack of such response shall be deemed as the applicant's acceptance of the board's ineligibility determination. If the applicant timely notifies the board of his or her intent to appeal the board's ineligibility determination to SOAH, a contested case before SOAH will be initiated only in accordance with §187.24 of this title (relating to Pleadings). The applicant shall comply with all other provisions relating to formal proceedings as set out in this title Chapter 187 Subchapter C (relating to Formal Board Proceedings at SOAH). If the applicant does not timely comply with such provisions, or if prior to the initiation of a contested case at SOAH, the applicant withdraws his or her notice of intent to appeal the board's ineligibility determination to SOAH, the applicant's failure to take timely action or withdrawal shall be deemed acceptance of the board's ineligibility determination. The committee may refer any application for determination of eligibility to the full board. All reports received or gathered by the board on each applicant are confidential and are not subject to disclosure under the Public Information Act. The board may disclose such reports to appropriate licensing authorities in other states.

(e) Applicants for licensure:

(1) whose applications have been filed with the board in excess of one year will be considered expired. Any fee previously submitted with that application shall be forfeited unless otherwise provided by §175.5 of this title (relating to Payment of Fees or Penalties). Any further request for licensure will require submission of a new application and inclusion of the current licensure fee. An extension to an application may be granted under certain circumstances, including:

(A) Delay by board staff in processing an application;

(B) Application requires Licensure Committee review after completion of all other processing and will expire prior to the next scheduled meeting;

(C) Licensure Committee requires an applicant to meet specific additional requirements for licensure and the application will expire prior to deadline established by the Committee;

(D) Applicant requires a reasonable, limited additional period of time to obtain documentation after completing all other requirements and demonstrating diligence in attempting to provide the required documentation;

(E) Applicant is delayed due to unanticipated military assignments, medical reasons, or catastrophic events;

(2) who in any way falsify the application may be required to appear before the board;

(3) on whom adverse information is received by the board may be required to appear before the board;

(4) shall be required to comply with the board's rules and regulations which are in effect at the time the completed application form and fee are filed with the board;

(5) may be required to sit for additional oral or written examinations that, in the opinion of the board, are necessary to determine competency of the applicant;

(6) must have the application of licensure complete in every detail 20 days prior to the board meeting in which they are considered for licensure. Applicants may qualify for a Temporary License prior to being considered by the board for licensure, as required by §185.7 of this title (relating to Temporary License);

(7) who previously held a Texas health care provider license, certificate, permit, or registration may be required to complete additional forms as required.

(f) Alternative License Procedure for Military Service Members, Military Veterans, and Military Spouses.

(1) An applicant who is a military service member, military veteran, or military spouse may be eligible for alternative demonstrations of competency for certain licensure requirements. Unless specifically allowed in this subsection, an applicant must meet the requirements for licensure as specified in this chapter.

(2) To be eligible, an applicant must be a military service member, military veteran, or military spouse and meet one of the following requirements:

(A) holds an active unrestricted physician assistant license issued by another state that has licensing requirements that are substantially equivalent to the requirements for a Texas physician assistant license; or

(B) within the five years preceding the application date held a physician assistant license in this state.

(3) The executive director may waive any prerequisite to obtaining a license for an applicant described in this subsection after reviewing the applicant's credentials.

(4) Applications for licensure from applicants qualifying under paragraphs (1) and (2) of this subsection shall be expedited by the board's licensure division. Such applicants shall be notified, in writing or by electronic means, as soon as practicable, of the requirements and process for renewal of the license.

(5) Alternative Demonstrations of Competency Allowed. Applicants qualifying under paragraphs (1) and (2) of this subsection:

(A) in demonstrating compliance with subsection (d) of this section must only provide sufficient documentation to the board that the applicant has, on a full-time basis, actively practiced as a physician assistant, has been a student at an acceptable approved physician assistant program, or has been on the active teaching faculty of an acceptable approved physician assistant program, within one of the last three years preceding receipt of an Application for licensure;

(B) notwithstanding the one year expiration in subsection (e)(1) of this section, are allowed an additional 6 months to complete the application prior to it becoming inactive; and

(C) notwithstanding the 20 day deadline in subsection (e)(6) of this section, may be considered for permanent licensure up to 5 days prior to the board meeting.

(g) Applicants with Military Experience.

(1) For applications filed on or after March 1, 2014, the Board shall, with respect to an applicant who is a military service member or military veteran as defined in §185.2 of this title (relating to Definitions), credit verified military service, training, or education toward the licensing requirements, other than an examination requirement, for a license issued by the Board.

(2) This section does not apply to an applicant who:

(A) has had a physician assistant license suspended or revoked by another state or a Canadian province;

(B) holds a physician assistant license issued by another state or a Canadian province that is subject to a restriction, disciplinary order, or probationary order; or

(C) has an unacceptable criminal history.

(h) Re-Application for Licensure Prohibited. A person who has been determined ineligible for a license by the Licensure Committee may not reapply for a license prior to the expiration of one year from the date of the Board's ratification of the Licensure Committee's determination of ineligibility and denial of licensure.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 29, 2018.

TRD-201802858

Stephen "Brint" Carlton, J.D.

Executive Director

Texas Medical Board

Effective date: July 19, 2018

Proposal publication date: February 2, 2018

For further information, please call: (512) 305-7016


CHAPTER 190. DISCIPLINARY GUIDELINES

The Texas Medical Board (Board) adopts amendments to §190.8, concerning Violation Guidelines, and §190.14, concerning Disciplinary Sanction Guidelines, with non-substantive changes to the proposed text as published in the March 16, 2018, issue of the Texas Register (43 TexReg 1555). The text of the rules will be republished.

The Board sought stakeholder input through Stakeholder Groups, which made comments on the suggested changes to the rules after a meeting held on November 16, 2017. The comments were incorporated into the proposed rules. Changes in the published rule, summarized below, respond to public comments or otherwise reflect non-substantive variations from the published rule. General Counsel Scott Freshour advises that the changes to the rules affect no new persons, entities, or subjects other than those given notice and that compliance with the adopted sections will not be more burdensome than under the proposed rules as published. The amendments will be republished.

The amendment to §190.8(6)(B) amends the rule to clarify that the Board will consider a misdemeanor to be a misdemeanor of moral turpitude if that type of misdemeanor has been found by a Texas Court to be a misdemeanor of moral turpitude; if the conviction involves dishonesty, fraud, deceit, misrepresentation, or violence; or if the conviction reflects adversely on a licensee's honesty, trustworthiness, or fitness to practice under the scope of the person's license. The rule also eliminates the word "deliberate" from the phrase "deliberate violence."

The amendment to §190.14 revises the chart to ensure that references to violations under Texas Occupation Code §164.053(a)(6) are referenced in the same section with violations under §164.053(a)(5).

The Board Received comments on the rules from the Texas Medical Association (TMA).

§190.8:

Comment: The TMA commented that it supported the proposed rule change allowing reliance on Texas Court's interpretation of what constitutes a misdemeanor of moral turpitude. The TMA additionally suggested clarifying that previous determinations by Texas Courts govern whether a crime is a crime of moral turpitude unless Texas Courts have not ruled on as a specific misdemeanor is a crime of moral turpitude. The TMA further comments that it opposes the Board's deletion of "deliberate" from the phrase "deliberate violence." The TMA believes that removing the requirement that a crime be a crime of "deliberate violence" rather than a crime of violence would expand the scope of misdemeanors involving moral turpitude.

Response: The Board agrees with the TMA comments that Texas court precedent should be the primary determiner of whether a crime constitutes a crime of moral turpitude and clarified this by re-organizing the format of the rule and adding the sentence "Those misdemeanors found by state courts in Texas not to be crimes of moral turpitude are not misdemeanors of moral turpitude within the act." The Board disagrees with the TMA that "deliberate violence" is an appropriate standard for evaluating a crime of moral turpitude. "Deliberate violence" is not a term that is used anywhere in the Texas Penal Code of Criminal Procedure and not included as an element in any misdemeanor crime in Texas. Further, any potential TMB finding that a misdemeanor of violence constitutes a crime of moral turpitude will be constrained by state court precedent. Accordingly, the Board will not incorporate TMA's suggestion to allow the word "deliberate" to remain in the phrase "deliberate violence."

§190.14:

Comment: The TMA comments that the Board possibly intended for the distinction related to prior Board disciplinary history to appear in both sets of violations for nontherapeutic prescribing under §164.053(a)(5) and (a)(6).

Response: The Board agrees with the TMA that the provisions related to prior disciplinary history for standard of care violations were intended to be included in both sections and accordingly adds the phrases related to prior disciplinary history accordingly.

SUBCHAPTER B. VIOLATION GUIDELINES

22 TAC §190.8

The amendments are adopted under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure.

§190.8.Violation Guidelines.

When substantiated by credible evidence, the following acts, practices, and conduct are considered to be violations of the Act. The following shall not be considered an exhaustive or exclusive listing.

(1) Practice Inconsistent with Public Health and Welfare. Failure to practice in an acceptable professional manner consistent with public health and welfare within the meaning of the Act includes, but is not limited to:

(A) failure to treat a patient according to the generally accepted standard of care;

(B) negligence in performing medical services;

(C) failure to use proper diligence in one's professional practice;

(D) failure to safeguard against potential complications;

(E) improper utilization review;

(F) failure to timely respond in person when on-call or when requested by emergency room or hospital staff;

(G) failure to disclose reasonably foreseeable side effects of a procedure or treatment;

(H) failure to disclose reasonable alternative treatments to a proposed procedure or treatment;

(I) failure to obtain informed consent from the patient or other person authorized by law to consent to treatment on the patient's behalf before performing tests, treatments, procedures, or autopsies as required under Chapter 49 of the Code of Criminal Procedure;

(J) termination of patient care without providing reasonable notice to the patient;

(K) prescription or administration of a drug in a manner that is not in compliance with Chapter 200 of this title (relating to Standards for Physicians Practicing Complementary and Alternative Medicine) or, that is either not approved by the Food and Drug Administration (FDA) for use in human beings or does not meet standards for off-label use, unless an exemption has otherwise been obtained from the FDA;

(L) prescription of any dangerous drug or controlled substance without first establishing a valid practitioner-patient relationship. Establishing a practitioner-patient relationship is not required for:

(i) a physician to prescribe medications for sexually transmitted diseases for partners of the physician's established patient, if the physician determines that the patient may have been infected with a sexually transmitted disease; or

(ii) a physician to prescribe dangerous drugs and/or vaccines for post-exposure prophylaxis of disease for close contacts of a patient if the physician diagnoses the patient with one or more of the following infectious diseases listed in subclauses (I) - (VII) of this clause, or is providing public health medical services pursuant to a memorandum of understanding entered into between the board and the Department of State Health Services. For the purpose of this clause, a "close contact" is defined as a member of the patient's household or any person with significant exposure to the patient for whom post-exposure prophylaxis is recommended by the Centers for Disease Control and Prevention, Texas Department of State Health Services, or local health department or authority ("local health authority or department" as defined under Chapter 81 of the Texas Health and Safety Code). The physician must document the treatment provided to the patient's close contact(s) in the patient's medical record. Such documentation at a minimum must include the close contact's name, drug prescribed, and the date that the prescription was provided.

(I) Influenza;

(II) Invasive Haemophilus influenzae Type B;

(III) Meningococcal disease;

(IV) Pertussis;

(V) Scabies;

(VI) Varicella zoster; or

(VII) a communicable disease determined by the Texas Department of State Health Services to:

(-a-) present an immediate threat of a high risk of death or serious long-term disability to a large number of people; and

(-b-) create a substantial risk of public exposure because of the disease's high level of contagion or the method by which the disease is transmitted.

(M) inappropriate prescription of dangerous drugs or controlled substances to oneself, family members, or others in which there is a close personal relationship that would include the following:

(i) prescribing or administering dangerous drugs or controlled substances without taking an adequate history, performing a proper physical examination, and creating and maintaining adequate records; and

(ii) prescribing controlled substances in the absence of immediate need. "Immediate need" shall be considered no more than 72 hours.

(N) providing on-call back-up by a person who is not licensed to practice medicine in this state or who does not have adequate training and experience.

(O) delegating the performance of nerve conduction studies to a person who is not licensed as a physician or physical therapist without:

(i) first selecting the appropriate nerve conductions to be performed;

(ii) ensuring that the person performing the study is adequately trained;

(iii) being onsite during the performance of the study; and

(iv) being immediately available to provide the person with assistance and direction.

(2) Unprofessional and Dishonorable Conduct. Unprofessional and dishonorable conduct that is likely to deceive, defraud, or injure the public within the meaning of the Act includes, but is not limited to:

(A) violating a board order;

(B) failing to comply with a board subpoena or request for information or action;

(C) providing false information to the board;

(D) failing to cooperate with board staff;

(E) engaging in sexual contact with a patient;

(F) engaging in sexually inappropriate behavior or comments directed towards a patient;

(G) becoming financially or personally involved with a patient in an inappropriate manner;

(H) referring a patient to a facility, laboratory, or pharmacy without disclosing the existence of the licensee's ownership interest in the entity to the patient;

(I) using false, misleading, or deceptive advertising;

(J) providing medically unnecessary services to a patient or submitting a billing statement to a patient or a third party payer that the licensee knew or should have known was improper. "Improper" means the billing statement is false, fraudulent, misrepresents services provided, or otherwise does not meet professional standards;

(K) behaving in an abusive or assaultive manner towards a patient or the patient's family or representatives that interferes with patient care or could be reasonably expected to adversely impact the quality of care rendered to a patient;

(L) failing to timely respond to communications from a patient;

(M) failing to complete the required amounts of CME;

(N) failing to maintain the confidentiality of a patient;

(O) failing to report suspected abuse of a patient by a third party, when the report of that abuse is required by law;

(P) behaving in a disruptive manner toward licensees, hospital personnel, other medical personnel, patients, family members or others that interferes with patient care or could be reasonably expected to adversely impact the quality of care rendered to a patient;

(Q) entering into any agreement whereby a licensee, peer review committee, hospital, medical staff, or medical society is restricted in providing information to the board; and

(R) commission of the following violations of federal and state laws whether or not there is a complaint, indictment, or conviction:

(i) any felony;

(ii) any offense in which assault or battery, or the attempt of either is an essential element;

(iii) any criminal violation of the Medical Practice Act or other statutes regulating or pertaining to the practice of medicine;

(iv) any criminal violation of statutes regulating other professions in the healing arts that the licensee is licensed in;

(v) any misdemeanor involving moral turpitude as defined by paragraph (6) of this section;

(vi) bribery or corrupt influence;

(vii) burglary;

(viii) child molestation;

(ix) kidnapping or false imprisonment;

(x) obstruction of governmental operations;

(xi) public indecency; and

(xii) substance abuse or substance diversion.

(S) contacting or attempting to contact a complainant, witness, medical peer review committee member, or professional review body as defined under §160.001 of the Act regarding statements used in an active investigation by the board for purposes of intimidation. It is not a violation for a licensee under investigation to have contact with a complainant, witness, medical peer review committee member, or professional review body if the contact is in the normal course of business and unrelated to the investigation.

(T) failing to timely submit complete forms for purposes of registration as set out in §166.1 of this title (relating to Physician Registration) when it is the intent of the licensee to maintain licensure with the board as indicated through submission of an application and fees prior to one year after a permit expires.

(3) Disciplinary actions by another state board. A voluntary surrender of a license in lieu of disciplinary action or while an investigation or disciplinary action is pending constitutes disciplinary action within the meaning of the Act. The voluntary surrender shall be considered to be based on acts that are alleged in a complaint or stated in the order of voluntary surrender, whether or not the licensee has denied the facts involved.

(4) Disciplinary actions by peer groups. A voluntary relinquishment of privileges or a failure to renew privileges with a hospital, medical staff, or medical association or society while investigation or a disciplinary action is pending or is on appeal constitutes disciplinary action that is appropriate and reasonably supported by evidence submitted to the board, within the meaning of §164.051(a)(7) the Act.

(5) Repeated or recurring meritorious health care liability claims. It shall be presumed that a claim is "meritorious," within the meaning of §164.051(a)(8) of the Act, if there is a finding by a judge or jury that a licensee was negligent in the care of a patient or if there is a settlement of a claim without the filing of a lawsuit or a settlement of a lawsuit against the licensee in the amount of $50,000 or more. Claims are "repeated or recurring," within the meaning of §164.051(a)(8) of the Act, if there are three or more claims in any five-year period. The date of the claim shall be the date the licensee or licensee's medical liability insurer is first notified of the claim, as reported to the board pursuant to §160.052 of the Act or otherwise.

(6) Discipline based on Criminal Conviction. The board is authorized by the following separate statutes to take disciplinary action against a licensee based on a criminal conviction:

(A) Felonies.

(i) Section 164.051(a)(2)(B) of the Medical Practice Act, §204.303(a)(2) of the Physician Assistant Act, and §203.351(a)(7) of the Acupuncture Act, (collectively, the "Licensing Acts") authorize the board to take disciplinary action based on a conviction, deferred adjudication, community supervision, or deferred disposition for any felony.

(ii) Chapter 53, Texas Occupations Code authorizes the board to revoke or suspend a license on the grounds that a person has been convicted of a felony that directly relates to the duties and responsibilities of the licensed occupation.

(iii) Because the provisions of the Licensing Acts may be based on either conviction or a form of deferred adjudication, the board determines that the requirements of the Act are stricter than the requirements of Chapter 53 and, therefore, the board is not required to comply with Chapter 53, pursuant to §153.0045 of the Act.

(iv) Upon the initial conviction for any felony, the board shall suspend a physician's license, in accordance with §164.057(a)(1)(A), of the Act.

(v) Upon final conviction for any felony, the board shall revoke a physician's license, in accordance with §164.057(b) of the Act.

(B) Misdemeanors.

(i) Section 164.051(a)(2)(B) of the Act authorizes the board to take disciplinary action based on a conviction, deferred adjudication, community supervision, or deferred disposition for any misdemeanor involving moral turpitude.

(ii) Chapter 53, Texas Occupations Code authorizes the board to revoke or suspend a license on the grounds that a person has been convicted of a misdemeanor that directly relates to the duties and responsibilities of the licensed occupation.

(iii) For a misdemeanor involving moral turpitude, the provisions of §164.051(a)(2) of the Medical Practice Act and §205.351(a)(7) of the Acupuncture Act, may be based on either conviction or a form of deferred adjudication, and therefore the board determines that the requirements of these licensing acts are stricter than the requirements of Chapter 53 and the board is not required to comply with Chapter 53, pursuant to §153.0045 of the Act.

(iv) The Medical Practice Act and the Acupuncture Act do not authorize disciplinary action based on conviction for a misdemeanor that does not involve moral turpitude. The Physician Assistant Act does not authorize disciplinary action based on conviction for a misdemeanor. Therefore these licensing acts are not stricter than the requirements of Chapter 53 in those situations. In such situations, the conviction will be considered to directly relate to the practice of medicine if the act:

(I) arose out of the practice of medicine, as defined by the Act;

(II) arose out of the practice location of the physician;

(III) involves a patient or former patient;

(IV) involves any other health professional with whom the physician has or has had a professional relationship;

(V) involves the prescribing, sale, distribution, or use of any dangerous drug or controlled substance; or

(VI) involves the billing for or any financial arrangement regarding any medical service;

(v) Misdemeanors involving moral turpitude. Misdemeanors involving moral turpitude, within the meaning of the Act, are those which:

(I) have been found by Texas state courts to be misdemeanors of moral turpitude;

(II) involve dishonesty, fraud, deceit, misrepresentation, violence; or

(III) reflect adversely on a licensee's honesty, trustworthiness, or fitness to practice under the scope of the person's license.

(vi) Those misdemeanors found by state Texas courts not to be crimes of moral turpitude are not misdemeanors of moral turpitude within the meaning of the Act.

(C) In accordance with §164.058 of the Act, the board shall suspend the license of a licensee serving a prison term in a state or federal penitentiary during the term of the incarceration regardless of the offense.

(7) Violations of the Health and Safety Code. In accordance with §164.055 of the Act, the Board shall take appropriate disciplinary action against a physician who violates §170.002 or Chapter 171, Texas Health and Safety Code.

(8) For purposes of §164.051(a)(4)(C) of the Texas Occupations Code, any use of a substance listed in Schedule I, as established by the Commissioner of the Department of State Health Services under Chapter 481, or as established under the Comprehensive Drug Abuse Prevention and Control Act of 1970 (21 U.S.C. §801 et seq.) constitutes excessive use of such substance.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 2, 2018.

TRD-201802954

Stephen "Brint" Carlton, J.D.

Executive Director

Texas Medical Board

Effective date: July 22, 2018

Proposal publication date: March 16, 2018

For further information, please call: (512) 305-7016


SUBCHAPTER C. SANCTION GUIDELINES

22 TAC §190.14

The amendments are adopted under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure.

§190.14.Disciplinary Sanction Guidelines.

These disciplinary sanction guidelines are designed to provide guidance in assessing sanctions for violations of the Medical Practice Act. The ultimate purpose of disciplinary sanctions is to protect the public, deter future violations, offer opportunities for rehabilitation if appropriate, punish violators, and deter others from violations. These guidelines are intended to promote consistent sanctions for similar violations, facilitate timely resolution of cases, and encourage settlements.

(1) The standard sanctions outlined in paragraph (9) of this section provide a range from "Low Sanction" to "High Sanction" based upon any aggravating or mitigating factors that are found to apply in a particular case. The board may impose more restrictive sanctions when there are multiple violations of the Act. The board may impose more or less severe or restrictive sanctions, based on any aggravating and/or mitigating factors listed in §190.15 of this chapter (relating to Aggravating and Mitigating Factors) that are found to apply in a particular case.

(2) The minimum sanctions outlined in paragraph (9) of this section are applicable to first time violators. In accordance with §164.001(g)(2) of the Act, the board shall consider revoking the person's license if the person is a repeat offender.

(3) The sanctions outlined in paragraph (9) of this section are based on the conclusion stated in §164.001(j) of the Act that a violation related directly to patient care is more serious than one that involves only an administrative violation. An administrative violation may be handled informally in accordance with §187.14(7) of this title (relating to Informal Resolutions of Violations). Administrative violations may be more or less serious, depending on the nature of the violation. Administrative violations that are considered by the board to be more serious are designated as being an "aggravated administrative violation."

(4) The maximum sanction in all cases is revocation of the licensee's license, which may be accompanied by an administrative penalty of up to $5,000 per violation. In accordance with §165.003 of the Act, each day the violation continues is a separate violation.

(5) Each statutory violation constitutes a separate offense, even if arising out of a single act.

(6) If the licensee acknowledges a violation and agrees to comply with terms and conditions of remedial action through an agreed order, the standard sanctions may be reduced.

(7) Any panel action that falls outside the guideline range shall be reviewed and voted on individually by the board at a regular meeting.

(8) For any violation of the Act that is not specifically mentioned in this rule, the board shall apply a sanction that generally follows the spirit and scheme of the sanctions outlined in this rule.

(9) The following standard sanctions shall apply to violations of the Act:

Figure: 22 TAC §190.14(9) (.pdf)

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on July 2, 2018.

TRD-201802955

Stephen "Brint" Carlton, J.D.

Executive Director

Texas Medical Board

Effective date: July 22, 2018

Proposal publication date: March 16, 2018

For further information, please call: (512) 305-7016


CHAPTER 198. STANDARDS FOR USE OF INVESTIGATIONAL AGENTS

The Texas Medical Board (Board) adopts amendments to §§198.1 - 198.4, and new §198.5 and §198.6. Sections 198.1, 198.3 and 198.6 are adopted without changes to the proposed text as published in the April 6, 2018, issue of the Texas Register (43 TexReg 2113) and will not be republished. Sections 198.2, 198.4 and 198.5 are adopted with changes to the proposed text as published in the April 6, 2018, issue of the Texas Register (43 TexReg 2113). The text of the rules will be republished.

The Board sought stakeholder input at the Stem Cell Stakeholder Group meetings on October 18, 2017, and on February 13, 2018, where stakeholders made comments on and suggested changes to the rules. The comments were incorporated into the proposed rules.

The Board amends Chapter 198 by dividing Chapter 198 into two separate subchapters, creating Subchapter A, Standards for Use of Investigational Drugs, Biological Products, or Devices. The purpose is to distinguish the applicability of the provisions contained in Subchapter A and those provisions contained in Subchapter B. Subchapter A contains §§198.1 - 198.4.

The Board adopts Subchapter B, Investigational Stem Cell Treatments for Patients With Certain Severe Chronic Diseases or Terminal Illnesses, which contains new §198.5 and §198.6, to distinguish the provisions contained therein with those provisions contained in Subchapter A.

The amendment to §198.1, concerning Purpose, removes the word "agents" and replaces it with the terms "drugs, biological products, or devices" in order to align with statutory language contained in Health and Safety Code Chapter 489. It also includes new language to distinguish the applicability of Subchapter A and to differentiate Subchapter B.

The amendment to §198.2, concerning Definitions, removes the definition of "investigational agent" and defines the terms "drugs, biological products, or devices" and "terminal illness." These proposed changes are consistent with the definitions and terms used in the Texas Health and Safety Code Chapter 489. The proposed changes also include limiting language to clarify that such definitions are not applicable to Subchapter B.

The amendment to §198.3, concerning Practice Guidelines for the Use of Investigational Agents, removes the term "agent" throughout the section and includes the terms "drugs, biological products, or devices" in line with statutory language contained in Health and Safety Code, Chapter 489.

The amendment to §198.4, concerning Use of Investigational Drugs, Biological Products, or Devices for Patients with Terminal Illnesses, changes the title of this section by removing the term "agent" and replacing it with the terms "drugs, biological products, or devices" in order to correspond with statutory terms in Chapter 489 of the Texas Health and Safety Code. The remainder of this section is deleted, as it is contained in Chapter 489 of the Health and Safety Code.

New §198.5, concerning Use of Investigational Stem Cell Treatments for Patients with Certain Severe Chronic Diseases or Terminal Illnesses, implements the requirements of House Bill 810, 85th Leg. R.S. (2017) which establishes the regulation of investigational stem cell treatments in Texas as set forth in Chapter 1003 of the Texas Health and Safety Code.

New §198.6, concerning Process and Procedures for IRBs Engaged in the Use of Investigational Stem Cell Treatments for Patients with Certain Severe Chronic Diseases or Terminal Illnesses, implements the requirements of House Bill 810, 85th Leg. R.S. (2017) which establishes the regulatory framework to allow investigational stem cell treatments in Texas through statutory changes in Chapter 1003 of the Texas Health and Safety Code.

SUMMARY OF COMMENTS. The Board received public written comments from Texans for Cures, an anonymous comment submitted through Cameron Duncan, and the Texas Hospital Association. Representative Tan Parker submitted public comments prior to the February 13, 2018, stakeholder meeting and several changes were made prior to publication of the proposed rule.

§198.1:

The Board received no public written comments and no one appeared to testify at the public hearing held on June 15, 2018.

§198.2:

A Representative commented that the definition of investigational drug should include the phrase "and remains under investigation in the clinical trial" in order to be consistent with the language of HB21 from the 84th legislative session.

Board Response: The Board has added this language to the definition of " investigational drug, biological product, or device" in order to be consistent with statutory language.

An individual submitted a comment on behalf of Right to Know commenting that the language is too broad any may interfere with the administration of over-the-counter medication.

Board Response: The Board declines to adopt the recommendations. The changes to Subchapter A are adopted in order to be consistent with the statutory language and are not an expansion or contraction of current regulatory authority.

§198.3:

The Board received one public written comment and no one appeared to testify at the public hearing held on June 15, 2018.

An individual submitted a comment on behalf of Right to Know commenting that the language is too broad any may interfere with the administration of over-the-counter medication.

Board Response: The Board declines to adopt the recommendations. The changes to Subchapter A are adopted in order to be consistent with the statutory language and are not an expansion or contraction of current regulatory authority.

§198.4:

The Board received no public written comments and no one appeared to testify at the public hearing held on June 15, 2018. However, a minor grammatical change is made. The word "remains" is changed to be singular, "remain".

§198.5:

The Board received two public written comments and no one appeared to testify at the public hearing held on June 15, 2018.

Texans for Cures commented that the Medical Board should have a single Institutional Review Board (IRB) for all stem cell clinical trials in Texas. The language should also be more specific, within the protection of HIPPA guidelines.

TMB Response: The TMB has considered the possibility of a single IRB for all physicians who are certified to administer stem cells in Texas. However HB810 does not give the TMB the authority through rulemaking to either create a universal stem cell IRB or to choose an existing entity to take on these responsibilities.

Texas Hospital Association states that the title of Subchapter B should be changed from "Diagnoses" to "Diseases" in order to be consistent with the statutory language. §198.5(c), the Texas Hospital Association states, contains a grammatical typo. §198.5(e), the Texas Hospital Association states, is unclear in its meaning. §198.5(e)(3), the Texas Hospital Association states, is difficult to reconcile with Texas Health and Safety Code §1003.055 and should be changed for clarity. Texas Hospital Association also proposes language to specify that affiliated hospitals licensed under Chapter 241 should have at least 150 beds and to include the eligible facilities instead of referencing statutory language.

TMB Response: The TMB agrees that Subchapter B should be changed from "Diagnoses" to "Diseases" in order to be consistent with the statutory language and TMB has made this non-substantive change to the final rule.

The TMB agrees with the Texas Hospital Associations comment regarding §198.5(c) and has corrected this typo.

§198.5(e) has been edited to clarify that the informed consent document signed by eligible patients must include language stating that the patient and the treating physician have considered and discussed all other federally approved treatment options and that the physician has determined that those treatment options are unavailable or unlikely to alleviate the patient's significant impairment or severe pain associated with the severe chronic disease or terminal illness. Texas Health and Safety Code §1003.053(2)(A) requires that all other federally approved treatment options be unavailable or most likely unsuccessful for a patient to be eligible to receive stem cell therapy in Texas under Chapter 198, Subchapter B. This language must be included in the informed consent document signed by the patient prior to any treatment by a certified physician. Although not explicitly included in the rule, a certified physician administering stem cells in Texas must keep a complete and accurate medical record. Here, this would include among other items, documentation of informed consent from the patient, documentation of all the required elements to establish that a patient is eligible to receive stem cell therapy, and documentation of the physician's consideration of other possible treatment options.

§198.5(e)(3) has not been changed in response to this comment. The language in this section is intended to clarify what entities, in addition to IRBs, may certify a physician. Texas Health and Safety Code §1003.055 states that a qualifying IRB may certify a physician to administer stem cell therapy in Texas as part of a clinical trial. The statute does not limit the certifying body to only qualifying IRBs. The Board rule clarifies that the entity with which a qualifying IRB is connected, as required by Texas Health and Safety Code §1003.055(d), may also certify a physician who will be administering stem cell treatments as part of the clinical trial overseen by the qualifying IRB. Thus the medical school or hospital connected to the qualifying IRB could utilize already established credentialing criteria to ensure that the physicians administering stem cell treatments to Texas patients, under the oversight of the IRB, are doing so in a safe and competent manner that is protective of Texas citizens. Although requiring that a hospital have at least 150 beds may possibly lead to a more thorough review of affiliated IRBs and more thorough processes for certifying physicians as discussed at the stakeholder meetings, there is no basis for this additional requirement in statutory authority.

The TMB declines to make changes to §198.5(e)(4) in the interest of ensuring that the rule is consistent with the statutory authority granted to the TMB to engage in this rulemaking.

§198.6:

The Board received one public written comment and no one appeared to testify at the public hearing held on June 15, 2018.

An anonymous comment states that the reporting requirements for IRBs are different from current IRB reporting requirements and could be burdensome to IRBs.

TMB Response: HB810 states that IRBs overseeing clinical trials involving the administration of stem cells must keep a record on each person who receives stem cells and the effects of the stem cell treatment. The statute also requires that the IRB report this information annually to the TMB. TMB's annual reporting requirements are intended to ensure that the annual IRB report has enough information to effectuate the will of the legislature to gather information about the administration of stem cell therapies within a clinical trial as allowed by HB810.

SUBCHAPTER A. STANDARDS FOR USE OF INVESTIGATIONAL DRUGS, BIOLOGICAL PRODUCTS, OR DEVICES

22 TAC §§198.1 - 198.4

The amendments are adopted under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure. The amendments are also adopted under the authority of §164.003(i) of the Texas Occupations Code.

§198.2.Definitions.

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Investigational drug, biological product, or device--A drug, biological product, or device that is not approved or licensed by the Food and Drug Administration (FDA) for use in humans and remains under investigation in a clinical trial. Investigational drugs, biological products, and devices may be used for the purposes of prevention, treatment, diagnosis or for relieving symptoms of a disease. An investigational drug, biological product or device shall not include:

(A) a drug, biological product, device, diagnostic product or treatment regimen approved by the FDA, but used for off-label purposes;

(B) a drug, biological product, device, diagnostic product or treatment regimen which is already approved for use by an existing Institutional Review Board (IRB);

(C) products processed or manufactured as human cell, tissue or cellular-or-tissue-based product ("HCT/P") pursuant to Sections 351 and 361 of the Public Health Service Act ("PHSA") (42 U.S.C. 264); or

(D) a drug, device or biological product pursuant to the federal Food Drug and Cosmetic Act (FDCA).

(2) Terminal illness--An advanced stage of a disease with an unfavorable prognosis that, without life-sustaining procedures, will soon result in death or a state of permanent unconsciousness from which recovery is unlikely.

(b) These definitions do not apply to Subchapter B of this title (relating to Investigational Stem Cell Treatments for Patients with Certain Severe Chronic Diseases or Terminal Illnesses).

§198.4.Use of Investigational Drugs, Biological Products, or Devices for Patients with Terminal Illnesses.

Investigational drugs, biological products, or devices which meet the criteria enumerated in §198.2, of this title (relating to Definitions) and have successfully completed phase one of a clinical trial and remain under investigation in the clinical trial shall be administered and provided to patients with terminal illnesses in accordance with applicable law, including Chapter 489 of the Texas Health and Safety Code.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 29, 2018.

TRD-201802904

Stephen "Brint" Carlton, J.D.

Executive Director

Texas Medical Board

Effective date: July 19, 2018

Proposal publication date: April 6, 2018

For further information, please call: (512) 305-7016


SUBCHAPTER B. INVESTIGATIONAL STEM CELL TREATMENTS FOR PATIENTS WITH CERTAIN SEVERE CHRONIC DISEASES OR TERMINAL ILLNESSES

22 TAC §198.5, §198.6

The new rules are adopted under the authority of the Texas Occupations Code Annotated, §153.001, which provides authority for the Board to adopt rules and bylaws as necessary to: govern its own proceedings; perform its duties; regulate the practice of medicine in this state; enforce this subtitle; and establish rules related to licensure. The new rules are also adopted under the authority of §164.003(i) of the Texas Occupations Code.

§198.5.Use of Investigational Stem Cell Treatments for Patients with Certain Severe Chronic Diseases or Terminal Illnesses.

(a) The Legislature recognizes the need for patient access to innovative medical treatments. At the same time, the health and welfare of Texas citizens must be protected. These goals must be carefully balanced.

(b) The purpose of this subchapter is to set out the requirements for a patient to be eligible for consideration of receiving investigational stem cell treatment and under what circumstances a certified physician may administer or provide investigational stem cell treatments. The implementation of this rule is contingent upon qualifying chronic diseases or terminal illness being defined, as set out in §1003.052 of the Texas Health and Safety Code.

(c) This rule does not require an eligible patient to receive such treatment, but rather the statute sets the eligibility standards and the parameters under which treatment may be provided to an individual with a qualifying severe chronic disease or terminal illness.

(d) Stem cell treatments which are under investigation in a clinical trial and being administered to human participants:

(1) may be administered or provided to eligible patients with qualifying terminal illnesses or severe chronic diseases as defined by the executive commissioner of the Health and Human Services Commission; and

(2) must be done in compliance with applicable law.

(e) In order for a patient to be eligible to receive treatment with investigational stem cells, the eligible patient must:

(1) be enrolled in a clinical trial investigating the use of adult stem cells in humans;

(2) sign a written informed consent, before receiving treatment, which includes documentation of compliance with §1003.053(2)(a) of the Texas Health and Safety Code;

(3) receive treatment from a physician certified under §1003.055 of the Texas Health and Safety Code by:

(A) a qualifying IRB;

(B) a medical school as defined by §61.501 of the Education Code; or

(C) a hospital licensed under Chapter 241 of the Texas Health and Safety Code; and

(4) receive treatment in a qualifying facility under §1003.055 of the Texas Health and Safety Code.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on June 29, 2018.

TRD-201802905

Stephen "Brint" Carlton, J.D.

Executive Director

Texas Medical Board

Effective date: July 19, 2018

Proposal publication date: April 6, 2018

For further information, please call: (512) 305-7016