EFTA00525314.pdf

Mission: To protect. promote & improve the health of all people in Florida through integrated state, county & community effons. HEALTH Vision:To be the Healthiest State in the Nation Rick Scott Governor Celeste Philip, MD, MPH State Surgeon General & Secretary Application Application Detail License Type: Dentist Profession Number: 701 - Dental License Number: 21635 Application: Reinstate Delinquent License Outside of Renewal Application Date: 07/10/2018 Personal Detail Title: Dr. First Name: KARYNA Last Name/Surname: SHULIAK Addresses Main Address Address: 6100 Red Hook Quarters Suite B-3 UNKNOWN ST THOMAS, VI 00802 US Phone Number: Extension: E-mail Address: Home Fax Physical Location Address: 6100 Red Hook Quarters 7/10/18 8:55 AM Page 1 of 3 EFTA00525314 Suite B-3 UNKNOWN ST THOMAS, VI 00802 US Phone Number: Extension: Questions related to Section 456.0635(3), Florida Statutes On or after July 1, 2009, have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar offense(s) in another state or jurisdiction? On or after July 1, 2009, have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970 (relating to controlled substances) or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare, Medicare and Medicaid issues)? On or after July 1, 2009, have you been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes? On or after July 1, 2009, have you been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program? Are you currently listed on the United States Department of Health and Human Services Office of Inspector General's List of Excluded Individuals and Entities? No No No No No Availability for Disaster Are you willing to provide health care services in special need shelters or to work with disaster medical teams during times of emergency or major disasters? No If you respond 'Yes', your name will be added to a data listing that is available to the Department of Health if a disaster is declared. If you live in an area where you may be able to help you will be called on if needed. Financial Responsibility/Exemption Financial Responsibility: Financial Exemption 7/10/18 8:55 AM Page 2 of 3 EFTA00525315 Financial Exemption 3. I am exempt from demonstrating financial responsibility because I practice exclusively as an officer, employee or agent of the federal government, or of the state or its agencies or subdivisions. 4. I am exempt from demonstrating financial responsibility because I practice only in conjunction with my teaching duties at an accredited school or in its main teaching hospitals. 5. I am exempt from demonstrating financial responsibility because I do not practice in the State of Florida. 6. I am exempt from demonstrating financial responsibility because I have no malpractice exposure in the State of Florida. Financial Exemption: 5. NOT PRACTICING IN FLORIDA Fees Delinquent $150.00 Unlicensed Activity $5.00 Active Renewal-Denta $300.00 Total Amount Due: $455.00 Attestation By submitting the appropriate renewal fees to the Department, I certify compliance with all requirements for renewal, including continuing education credits. I am responsible for knowing these requirements as set forth in the laws and rules of my profession. Attestation Answer: Yes 7/10/18 8:55 AM Page 3 of 3 EFTA00525316