EFTA00525167.pdf

UnitedHealthcare 01/30/2019 KARYNA SHULIAK 6100 RED HOOK QTRS SUITE B-3 ST. THOMAS, VI 00802 Dear KARYNA SHULIAK: RE: Coverage Approval Patient: KARYNA SHULIAK Physician: ELLEN MARMUR File ID: PA-53100240 Date of Request: 01/30/2019 Date of Decision: 01/30/2019 We are pleased to inform you that your prescription for CLARAVIS has been approved for coverage up to the plan's supply limit for this medication. This medication is approved for coverage until 07/30/2019, or until coverage for the medication is no longer available under the benefit plan or the medication becomes subject to a pharmacy benefit coverage requirement, such as supply limits or notification, whichever occurs first. You will be responsible for paying your copayment and any additional amount, as required by the provisions of your pharmacy benefit. Your UnitedHealthcare Insurance Company prescription drug program is administered by OptumRx. For certain drugs, more information is needed to determine coverage eligibility. In these cases, your physician must supply the additional information needed to determine if the coverage conditions have been met. The information your physician provided was reviewed and the coverage was approved. A letter was sent to your physician informing him or her of the decision. UnitedHealthcare encourages members to take an active role in their health care. If you have questions about this coverage decision, please call a representative at 1-800-711-4555. Representatives are available to help you 5 a.m. - 10 p.m. PT, Monday-Friday and 6 a.m. — 3 p.m. PT, Saturday. Thank you for choosing UnitedHealthcare. Sincerely, OptumRx EFTA00525167 BUSINESS. CONSUMER SERVICES. AND HOUSING AGENCY- Department of Consumer Affairs GAVIN NEWSOM. GOVERNOR idea- Di Oak IPAnd I Y. CONSIOnt• Mir I Mel LICENSEE NAME SHULIAK, KARYNA DENTAL BOARD OF CALIFORNIA 2005 Evergreen Street Suite 1550 Sacramento, CA 95815 (916) 263-2300 www.dbc.ca.gov Dental License Renewal Notice EXPIRATION LICENSE NO. DATE DDS65268 05/31/19 I. Renewal Instructions AMOUNT DUE NOW 5662.00 AMOUNT DUE IF POSTMARKED AFTER JUNE 30.2019 $987.00 Attention: • To Renew Online, visit www.breeze.ca.gov. Online renewals are processed in 48-72 hours. If not renewing online, please read the renewal instructions below. Allow 6-10 weeks for processing your renewal when renewing by mail. • Do not send the delinquent fee amount unless your renewal will be postmarked 30 days after the expiration date of your license. • YOU MAY NOT ENGAGE IN THE PRACTICE OF DENTISTRY AFTER THE EXPIRATION DATE UNLESS THE LICENSE IS RENEWED. • Failure to complete the CE certification and sign at the bottom of page 5 will result in a delay of your renewal. Renewal Checklist: O IMPORTANT: Read all instructions. Answer the questions on the application by checking the appropriate boxes and sign and date the certification statement at the bottom of page 5. Failure to correctly complete the renewal application and documentation will result in processing delays. Applications received without a signature will not be processed. O Complete the required information on pages 3-6 in black or blue ink and make a copy for your records. O Sections I thru 5 of the Dental Healthcam Workforce Survey on page 3 must be completed. The information collected in this survey will be publicly available in accordance with state law. O Continuing Education (CE) information must be completed. Read the Continuing Education Requirements on page 2 then carefully mark the appropriate answers on page 5. O Return pages 3-6 in the enclosed envelope with a check or money order made payable to the Dental Board of California (DBC). Make sure the return address shows through the window of the envelope. Denial License Renewal Notice. 440.RNWL03. /2/8/8: Page 1 of 6 EFTA00525168 Page 2 of 6; Dental License Renewal, 440.RNWL03. /2/8/8 SHULIAK, KARY DDS65268 ii. Renewal Requirements Change of Name or Address: Make address changes in the space provided on the back side of the cashiering coupon. Please write as legibly as possible. Note: your name and address of record are public information, and are released to the public upon request. If you have a name change that you would like to have processed with the renewal application, submit: I) the 'Notification of Name Change' form (found under 'Forms and Publications' on the Board's website) and 2) photocopies or electronic copies of the following two required documents: A current government-issued photographic identification (e.g., driver license, alien registration, passport, etc.) AND one of the following legal documents as proof of name change (certified court order, marriage certificate, or dissolution of marriage [divorce]. Your renewal will not be processed until the name change is completed. Continuing Education: l'he laws of the State of California require certification of the following: • Completion of at least 50 hours of continuing education during each two year renewal period. • Completion of a course in Basic Life Support which is approved by the American Heart Association (AHA) the American Red Cross (ARC) , the American Dental Association's Continuing Education Recognition Program (CERP) or the Academy of General Dentistry's Program Approval for Continuing Education (PACE). • Completion of 2 units in Infection Control and 2 units in the California Dental Practice Act. Conviction Disclosure: CCR„ Section 1008(6) states as a condition of renewal, a licensee shall disclose whether, in the prior renewal cycle, he or she has been convicted of any violation of the law in this or any other state, the United States, or other country, omitting traffic infractions under 51,000 not involving alcohol, dangerous drugs, or controlled substances. In addition, a licensee must disclose any disciplinary actions against any other license he or she may hold. If you are answering yes to this question, please provide a detailed explanation of the circumstances surrounding the conviction or disciplinary action and provide documentation (Disciplinary Order, Court and/or Arrest records). Fingerprint Requirement: For a license that expires after July 1, 2011, as a condition of renewal of license, a licensee who was initially licensed prior to July 1, 1999, or for whom an electronic record of the submission of fingerprints does not exist, shall furnish to the Department of Justice a full set of fingerprints for the purpose of conducting a criminal history record check and to undergo a state and federal level criminal offender record information search conducted through the Department of Justice. Failure to comply with the requirements of this section renders any renewal incomplete and the license will not be renewed until the licensee demonstrates compliance with all requirements. Failure to furnish a full set of fingerprints to the Department of Justice as required by this section on or before the date required for renewal of a license is grounds for discipline by the Board. Licensees who are required to provide fingerprints were notified in a separate letter from the Board. Licensees are not required to fingerprint at each renewal. CURES Requirement: Pursuant to Business and Professions Code Section 208 (SB809 — DeSaulnier, Chapter 400, Statutes of 2013), you are assessed 56 ANNUALLY which is collected at the time of renewal to cover the operation and maintenance of the Controlled Substance Utilization Review and Evaluation System (CURES). For the Dental license only. EFTA00525169 Page 3 of 6; Dental License Renewal, 440.RNWL03.121818 SHULIAK, KARY DDS65268 iii. Dental Healthcare Workforce Survey Sections 1, 2, 3, 4, and 5 are required. Business and Professions Code section 1715.5 requires completion of this survey. The survey Information collected will be publicly available in accordance with state law. I. LICENSE NUMBER: 2. LICENSE TYPE: O DDS O RDH O RDHEF O O O RDHAP RDA RDAEF 3. EMPLOYMENT STATUS: O Full-time clinical practice in CA (32+ hours per week) O Full-time clinical outside CA (32+ hours pa week) O Pan-time clinical practice in CA (Less than 32 hours per week) O Administrative/Faculty Employment (No Direct Patient Care) O Retired O Other practice or employment status 4a. PRIMARY PRACTICE LOCATION: If you provide patient care, please Indicate the zip code of your primary practice location (U.S. only) and the number of hours spent each week at this location. 4b. SECONDARY PRACTICE LOCATION: If you provide patient care in a second location, please indicate the zip code of that practice location (U.S. only) and the number of hours spent each week at this location. ZIP CODE ZIP CODE HOURS PER WEEK HOURS PER WEEK 5. POSTGRADUATE TRAINING: Indicate the total years of training completed after dental school (accredited by the Committee on Dental Accreditation in a dental specialty recognized by the American Dental Association). O I O 2 O 3 O 4 O 5+ O None 6. DENTAL PRACTICE/SPECIALTY and BOARD CERTIFICATIONS or PERMITS: (mark specialty classifications and Board Certifications) O General Practice O Endodontics O Prosthodontics O Maxillofacial O Oral Pathology O Oral Radiology O Public Health O Pediatric Dentistry O Orthodontics O Periodontics O Facial Cosmetic Surgery O General Anesthesia O Oral Conscious Sedation O Conscious Sedation 7. ETHNIC BACKGROUND (Optional): Mark all that apply O African American / Black / African O American Indian / Native American / Alaskan Native Asian Latino / Hispanic O Cambodian O Korean O Central O Chinese O Thai American O Indian O Vietnamese O South O Indonesian O Other Asian American O Puerto Rican O Japanese O Caucasian / White / European / Middle Eastern O Other O Decline to State Native Hawaiian / Pacific islander O Cuban O Fijian O Mexican O Filipino O Other O Guamanian Hispanic O Hawaiian O Samoan O Tongan O Other Pacific Islander 8. FOREIGN LANGUAGE (Optional) In addition to English, indicate additional languages in which you are fluent: O American Sign O Farsi O Hmong O Lao O Punjabi O Thai Language O French O Ilacano O Mandarin O Russian O Turkish O Arabic O German O Italian O Mien O Samoan O Vietnamese O Armenian O Hebrew O Japanese O Polish O Spanish O Decline to State O Cambodian O Hindi O Korean O Portuguese O Tagalog O Other: O Cantonese EFTA00525170 Page 4 of 6; Dental License Renewal, 440.RNWL03.121818 SHULIAK, KARY DDS65268 el EFTA00525171 Page 5 of 6; Dental License Renewal, 440.RNW1.03.121818 SHULIAK, KARY DDS65268 v. Renewal Application (Return entire page. Fold according to instructions on reverse side) Question 1: Continuing Dental Education Read each statement carefully and mark the appropriate answer. A. Have you completed and can document 50 hours of approved continuing education in the last two years? B. Have you completed and can document completion of a course in Basic Life Support by the AHA or ARC, PACE or CERP? C. Have you completed the mandatory 2 hour course in Infection Control? D. Have you completed the mandatory 2 hour course in California Dental Practice Act? E. Is this your first renewal and you are not required to have CE units? Yes No Did you check Yes to statements "A," through "D," above, as required for active renewal? • If Yes, check box "A," and box "C," below. (No CE Units arc required until license is reactivated.) • If you would like to renew Inactive, check box "B," below. • If this is your first renewal and you are not required to have CE units, answer yes to statement "E." above and check box "A," and "C," below. Question 2: Change of Address Has a change of address occured? • If Yes, check Box "E," below and complete the Change of Mailing Address on the reverse side. Question 3: Conviction Disclosure Since you last renewed your license, have you had any license disciplined by a government agency or other disciplinary body, or, have you been convicted of any crime in any state, the U.S.A. and its territories, military court or a foreign country? (Please read information on page 2 before answering.) • If Yes, check box "F," below. • If No, check box "G," below. Question 4: Fingerprints Have you furnished a full set of fingerprints to the Department of Justice as required by Title 16, California Code of Regulations Section 1008? (Please read information on page 2 before answering) • If Yes, check box "H" below. • If No, check box "I" below. Dental Board of California — Dental License Renewal LICENSEE NAME SHULIAK, KARYNA (DO NOT DETACH) LICENSE NO. DDS65268 LICENSEE MUST CHECK CORRECT BOXES 'CO E. K T K - 14. K Renew Active li* K Renew Inactive CE Completed /CE Waiver Change of Address (fill in reverse side) Conviction Disclosure - Yes Conviction Disclosure - No Fingerprint - Yes *T. K Fingerprint - No EXPIRATION DATE 05/31/19 AMOUNT DUE IF AMOUNT POSTMARKED AFTER DUE NOW JUNE 30,2019 5662.00 5987.00 SIGNATURE REQUIRED I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature Date 36100404190404191000652685010531190006620000098700 EFTA00525172 Page 6 of 6; Dental License Renewal, 440.RNWL03.121818 SHULIAK, KARY DDS65268 RETURN ADDRESS STATE OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS PO BOX 942511 SACRAMENTO CA 94258-0511 CHANGE OF MAILING ADDRESS Email I T6 P 1 ****** ******"*******SNGLP KARYNA SHULIAK 6100 RED HOOK QUARTER SUITE B-3 ST THOMAS VI 00802 'Jr FOLD HERE 'Jr T6 P1 SHULIAK, KARY DDS65268 ;Peet Address 1 I I I l l I I I :ity I I I I I I O Box (if used, must provide a confidential physical street address, above) I I I I I State Zip ity I I I I I l l l l State Zip EFTA00525173 0 0 la 1 Onaipt at =ICS OCPAPPACNIC/ COM:LIMA' MrMal , BUS.. EES CONEuvER SERVICES. +D HOUS010 AGENCY - GAVIN NEWSOM, GOVERNOR Dental Board of California 2005 Evergreen Street, Suite 1550, Sacramento, California 95815 P 916.263.2300 l F 916.263.2140 l www.dbc.ca.gov Electronic Mail (Email) Address Requirement Notice: All Dental Board applicants and licensees must report to the Board his or her electronic mail address no later than July 1, 2016. Business and Professions Code Section 1650.1 requires all applicants and licensees of the Dental Board of California to report to the board his or her electronic mail address, and will require the board to annually send an electronic notice to each applicant and licensee that requests confirmation of the applicant's or licensee's electronic mail address. If you have not yet submitted your electronic mail address to the board, please do so now. To submit by email send to Dentalboard@dca.ca.gov, or to submit by fax send to (916) 263-2140. Include your full name and license number, and license type. INS440DBC-13-20160720 EFTA00525174 STATE OF CALIFORNIA 0 C S DEPARTMENT OF CONSUMER AFFAIRS Business and Profession Code Section 114.5 requires all boards, bureaus, committees and commissions within the Department of Consumer Affairs to ask whether an applicant or licensee is serving in, or has previously served in, the military. Answering this question is optional but if you have checked "YES" below, please complete and return this insert with your renewal coupon. Are you currently serving, or have you previously served, in the military? YES 0 If checked YES, please return this form with your renewal, completing the information below. Name: License Type: License Number: INS-00IALL-01-20150922 EFTA00525175