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IN THE MATTER OF * BEFORE THEMARC S. POSNER, M .D. * MARYLAND BOARD OF

Respondent * PHYSICIANSLicense Num ber: D19640 * Case N um ber: 2001-0482* * * * * * * * * * * *

CONSENT ORDERPROCEDURAL BACKGROUNDOn August 26, 2004, the Maryland Board of Physicians (the "Board")

charged Marc S. Posner, MD,. (the "Respondent"), OOB: 06/02/50, LicenseNumbe r 0 19 640 , w ith viola ting th e Maryla nd Med ical P ra ctice A ct (th e "A ct"), M d.H ea lth O cc. C od e Ann . ("H .O .") 14-101 e t s eq . (2000).

The pertinent provisions of the Act under H .O . 14-404(a) provide asfollows:

S ubject to the hearing provisions of 14-405 of this subtitle,the Board, on the affirmative vote of a m ajority of the quorum , m ayreprimand any licensee, place any licensee on probation, orsu sp en d or revo ke a lice nse if th e lice nsee :(3 ) Is g uilty of immora l or u np ro fe ssion al co ndu ct in th e pra ctice o fmedicine;(22) F ails to mee t a pp rop riate stan dard s a s de te rm ine d b yapp ropria te pee r re view fo r th e deliv ery o f q ua litymed ical a nd surg ical ca re p erfo rmed in an ou tpa tie ntsurg ical fa cility , o ffic e, hospita l, o r any o ther lo ca tionin this S tate; a nd(40) Fails to keep adequate medical records as determ ined by

a pp ro pria te p ee r re view.On December 1, 2004, a conference w ith regard to this matter was held

before the Case Resolution Conference ("CRC"). As a result of negotiationsentered into after the CRC, the Respondent agreed to enter into this Consent

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Order, consisting of Procedural Background, Findings of Fact, Conclusions ofLaw and Order.

FINDINGS OF FACT1. At all tim es relevant hereto, the Respondent, who is board-certified

in fam ily practice and geriatric medicine, was and is licensed topractice m edicine in the State of M aryland. The Respondent wasorig inally licensed to practice m edicine in M aryland on August 9,1976.

2. The R espondent m aintains an office for the practice of m edicine at430 S. Hanover Street, Baltim ore, M aryland and has privileges atHarbor Hospita l Center, G reater Baltimore Medical Center, UnionMemorial H ospita l and a number of nursing homes in the B altim orearea.

P ro cedura l Bac kg round

3. On or about October 15, 1998, the Maryland D ivision of DrugControl notified the Board that a pharmacist had expressedconce rns rega rd ing the Respondent's p resc rib ing p ractices .

4. Thereafter, the Board reviewed the C laim and initiated aninvestigation o f th is ma tte r.

5. Pursuant to its investigation, the Board referred the matter to thePeer Review Management Committee ("PRMC") of the Medical andChirurgical Faculty of Maryland ("Med-Chi") for a review of theRespondent's practice subsequent to November 6, 1996, the date

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he became a Diplomate of the American Academy of PainManagement.1

6. On or about January 28, 2000. the Med-Chi Peer ReviewCommittee (the "PRC") issued a written report of its findings to theBoard.

7. Thereafter, the Board voted to share w ith the R espondent som e ofthe concerns expressed in the peer review report and on May 12,2000, issued an Advisory Letter to the R espondent.

8. The Advisory Letter set forth the peer reviewers' concerns asfollows:

1. When prescrib ing quantities of controlled substancewhich h ave a sign ifican t a bus e p oten tia l, th e ra tio na le fo rp re scrib ing th ese med icatio ns sh ou ld b e in g re ate r de ta ilthan could be found in your charts.2. The documentation and physical exam ination, medicalrecords, narrative reports, as well as additionalinformation to support the need for not only controlled

substances but also for additional services such asphy sic al th era py , is s ig nific an tly d efic ie nt.3. There was an unusual connection of repeated medicalvisits which necessitated frequent and excessivenarcotic m edications, particularly for those individualspartic ipating in physical therapy w ithout sufficient detail

to assist in reaching this conclusion.

1 The Am erican Academy of Pain Managem ent ("AAPM ") is the Am erican Medical Association-rec og niz ed s pe cia lty s oc ie ty o f p hy sic ia ns who pra ctic e p ain med ic in e. A cc ord in g to AAPMpub lic atio ns , its m is sio n is to "e nh an ce p ain med ic in e p ra ctic e in this c ou ntry b y p romo tin g asoc io econom ic and politic al c lima te conducive to th e e ffe ctiv e and e ffic ie nt p ra ctic e o f p ainman ag emen t a nd b y e ns urin g qu ality med ic al c are b y p hy sic ia ns s pe cia liz in g in p ain med ic in e,fo r p atie nts in n ee d o f s uc h s erv ic es ." AAPM c re de ntia lin g is v olu nta ry ; th e D ip loma te le ve lin dic ate s th at th e c re de ntia le d in div id ua l h as a d oc tora te d eg re e in a re la te d h ea lth c are fie ld , am in imum o f two (2 ) yea rs c lin ic al e xperie nce work in g w ith in div id ua ls suffe rin g w ith pain , to okpain managemen t c la sses and passed a w ritte n e xam inatio n.

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9.

10.

11.

a.

The Advisory Letter further inform ed the Respondent that hispractice w ould be subject to chart and/or peer review w ithin six(6) m onths from the date of the A dvisory Letter.In or around M arch 2001, the Board conducted a chart reviewof 6 of the R espondent's patients. It w as later determ ined thatthe chart review was conducted without benefit of a drugsurvey. The Board thereafter referred the m atter to the M ed-Chi PRC for a peer review of six (6) patient charts other thanthose that had previously been reviewed by the Board. TheBoard instructe d th e p ee r reviewe rs to re view the Resp ond ent'scare as of November 2000, six (6) months subsequent to theMay 1 2, 2 000 Adviso ry L ette r.The resulting peer review report w as issued on or about M arch13, 2003. The peer review report stated that the Respondentfailed to m eet appropriate standards for the delivery of qualitym edical care for reasons w hich included, but w ere not lim ited,to the fo llow ing genera l defic ienc ies:

The Respondent's documentation during the reviewperiod, Novembe r 2000 through O ctober 2001, had notim pro ve d a ppre ciab ly from do cumen tatio n th at ha d b ee ncriticized in the Advisory Letter. The Respondent failedto document in sufficient detail the patients' history,physical findings and treatment rationale when

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prescrib ing Controlled Dangerous Substances ("CDS")that have a high addictive potentia l;

b. The Respondent consistently failed to docum ent histreatm ent rationale for increasing the dosage of ScheduleII C DS ;

c. The Respondent prescribed CDS on a m onthly basiseven when evaluations conducted by other specialistsfailed to support the patient's need for narcoticanalgesics;

d. The Respondent failed to decrease the dosage ofSchedule II CDS despite docum ented im provem ent inpatients ' condi tions;

e. The Respondent prescribed benzodiazepines inconjunction w ith C DS and w ithout w arning patients of thep os sib le a dv ers e s id e e ffe cts .

PAT IENT-SPECIF IC F INDINGS OF FACTPatient A 6

12. P atient A , a fem ale born in 1961, first presented to the R espondenton Novem ber 8, 1999 with com plaints of right elbow pain. TheRespondent prescribed Lorcet, a Schedule III CDS opioidanalgesic, and Voltaren, a non-C DS nonsteroidal anti-inflam matoryd ru g (" NS A ID ").

2 To ensure confidentia lity, the patients' nam es are not used in this Consent Order.

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16.

17.

13. The Respondent's notes prior to the review period indicate thatPatient A returned to the Respondent on December 7, 1999, stillcom plaining of elbow pain. The Respondent noted that her elbowpain had not changed and diagnosed her as having epicondylitis.He prescribed O xycontin 10m g (#60).

14. Thereafter, Patient A returned to the Respondent on a monthlybasis. On April 25, 2000, Patient A presented w ith com plaints ofback pain, for which the Respondent and physician assistants("PA") employed in his office thereafter noted a diagnosis of either"lum bar strain" or "lum bar disc disease."

15. At each of Patient A 's m onthly visits from D ecem ber 1999 throughAugust 2000, the R espondent prescribed 60 tablets of O xycontin10 mg q 12 hours and an unspecified quantity of Motrin 800 mg tobe taken 3 tim es a day.In October 2000, the Respondent referred Patient A to a painmanagement clinic. The consulting physician, Physician A,e xamin ed Patien t A an d re po rte d th at sh e p re se nted w ith p rese nte dwith myofascial pain involving the left posterior quadrant of herback, but he did not feel that there w as significant lum bar pathologyo r th at th e patie nt man ife ste d s ig nific an t p ain behav io r.From September 2000 through December 2000, the Respondentincreased from sixty (60) to ninety (90) the num ber of O xycontin 10mg tablets that he prescribed to Patient A and increased the

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18.

dosage frequency from one (1) tablet every twelve (12) hours toone (1) tablet every eight (8) hours. The Respondent failed todo cument eith er th e med ica l ne ce ssity o r his tre atment ratio na le fo rin creas ing the dosage frequency .O n January 2, 2001, the Respondent increased the dosage ofoxycontin from 10 mg every eight (8) hours to 20 mg every eight(8) hours. The Respondent failed to document either the medicalnecessity or his treatment rationale for doubling the dosage of theCDS. The Respondent documented that Patient A "feels OK" andhas full ROM [range of m otion] in her right elbow .

19. The Respondent continued to prescribe O xycontin 20 m g, q 8h #90to Patient A at each of her monthly office visits throughout theremainder of the review period in the absence of documentednecessity fo r the prescr ip tion .

20. On July 19, 2001, Patient A underwent a magnetic resonanceim age ("MRI") study of her lum bar spine. The results indicated m ilds pondylo tic c hanges a t L 2-3 , b ut were o th erw is e unremarkab le .

21. On August 17, 2001, Patient A was seen by a PA in theRespondent's practice. The PA noted that she had discussed w ithPatient A alternative treatm ent. Patient A refused the treatm entalternatives and continued to receive ninety (90) tablets ofO xycontin 20 m g at each m onthly visit during the rem ainder of there view period.

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22. The Respondent failed to meet the standard of care for the deliveryof quality medical services to Patient A for reasons including, butnot lim ited, to the follow ing:

a. The Respondent's documentation of his care of Patient A isdefic ie nt. H is note s o f Patie nt A 's h is to ry , p hy sic al e xam inatio nsand treatment plan and rationale are inadequate to support thechronic prescription of Oxycontin. The Respondent'sdocumentation fails to support a diagnosis of lumbar discdisease or any sort of radicular pain or disc herniation;

b. In January 2001, the Respondent increased the dosage ofOxycontin from 10 mg to 20 mg in the absence of supportingdocum entation of w orsening sym ptom s and docum entation ofh is tre atmen t ra tio na le fo r in creas in g th e dosage;

c. The Respondent continued to prescribe 20 m g of oxycontin ona chronic basis to Patient A follow ing a near-normal MRI andthe absence o f s uffic ie nt d ocumen ta tio n; a nd

d. The R espondent did not decrease dosage of oxycontin despitethe absence of an objective finding that Patient A 's pain hadworsened.

Patient B24. The Respondent began treating Patient B, a female born in 1952, in

May 1997 and treated her for cervical disc disease, low back pain,

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lum bar disc disease, anxiety, hypercholesterolem ia and urinaryincontinence.

25. The Respondent's notes prior to the review period indicate that hebegan prescrib ing Percocet, a Schedule \I CDS, to Patient B in July1998 w hen she com plained of back pain.

26. From Decem ber 1998 through Septem ber 2001, the Respondent sawPatient B on a m onthly basis for com plaints of back pain andprescribed to her Oxycontin and Percocet during the sam e tim ep erio d fo r lu m ba r d is c d is ea se .

27. O n April 2, 1999, Patient B com plained that the pain m edication w asnot strong enough in response to w hich the Respondent doubled theOxycontin dosage from 10 m g to 20 m g.

28. O n August 10, 1999, the Respondent referred Patient B to aneurosurgeon who reviewed an M RI study that Patient B hadundergone in January 1999. The neurosurgeon noted that Patient Bcom plained of neck pain and num bness and tingling in her hands.The neurosurgeon found evidence of cervical spondylosis at C5-6and noted m ild radicular sym ptom s down the left upper extrem ity.The neurosurgeon did not m ention lower back sym ptom s. O nSeptem ber 20, 1999, a PA noted that Patient B had taken all her painm edication before she was due for a refill. The PA noted that PatientB 's Oxycontin was to be increased at the next visit. The PA alsoadded Percocet to Patient B 's drug regim e.

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29. The Respondent failed to meet the appropriate standard of care forthe delivery of quality medical services to Patient B for reasonsincluding, but not lim ited to the follow ing:

a. The Respondent's documentation of his care of Patient B isdeficient. His notes of Patient B 's history, physical exam inations,treatment plan and rationale are inadequate to support the continuedprescription of O xycontin and Percocet;b. The Respondent's documentation, including history, recordedp hysica l find ing s a nd ra dio log ical stu die s, fa ils to su ppo rt a dia gn osiso f lumba r d is c d is ea se ;c. The Respondent failed to adequately document the treatmentrationale for doubling the dosage of O xycontin;d. In September 2001, the Respondent increased the dosage ofTranxene from 3.75 mg to 7.5 mg in the absence of supportingdocumenta tion; ande. The Respondent failed to document the medical necessity forp resc rib ing a benzodiazepine in con junc tion w ith Oxycon tin .Patie nt C

37. Patient C , a female born in 1925, initia lly presented to theRespondent August 1984. Her past m edical history includes:congestive heart fa ilure, chronic obstructive pulm onary diseasech ro nic a tria l fib rilla tion a nd tra nsitio nal ce ll ca ncer o f the bla dde r.Patient C 's progress notes prior to the review period indicate that

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38.

39.

40.

41.

th e Resp ond ent h ad p re scribe d F io rin al, a S ch edu le III ba rb itura te ,and Em pirin w ith codeine to her for over ten (10) years for pain. Inor around June 1999, the Respondent began prescribing Percocetfor Patient C 's complaints of pain. In March 2000, Patient C wasseen by a gastroenterologist and complained of rectal pain. Thephysician noted in his report that Patient C had requested painm edication on several occasions during the visit. H e further notedthat he w as aw are that she was already taking pain m edication andthat he was reluctant to prescribe her any more medication untils he had a s igmo id os copy .In late 2000, P atient C complained of fatigue and intravaginal pain.The R espondent attem pted a tria l of O xycontin, but sw itched backto P ercocet after documenting that P atient C w as unable to tolerateOxycontin.Patient C was seen periodically by a urologist to monitor herb ladder cancer .On November 30, 2000, Patient C underwent a gynecologicalconsultation. The consulting physician noted that Patient Chadon goin g complain ts o f p elvic p ain a nd in crea se d u rina ry fre qu encyand u rgency .The Respondent continued to prescribe Percocet, providingPatient C w ith prescriptions for Percocet (each in quantities oftwenty-five (25) or thirty (30) tablets). Specifically, at each of

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Patient C 's monthly visits from December 2000 through October2001 the Respondent prescribed, or authorized the prescription of,Percocet and noted "3 rx" for each prescription. A review of theprescriptions that were written by the Respondent and filled byPatient C at an area pharmacy reveal the follow ing: 1) manyprescriptions are not dated; 2) several of the prescriptions that aredated do not correspond to the dates of office visits and are nototherw ise documented in Patient C 's chart; and 3) more than three(3) P ercocet prescriptions w ere w ritten for several of the m onths inth is time period.

42. Failure to date Patient C 's Percocet prescriptions is a violation offe de ra l a nd s ta te re gu la tio ns . See, 21 CFR 1306.05; Code Md.Regs . ("COMAR") tit. 10 , 19 .03.07(E )(1 ).

43. T he R espondent failed to m eet the appropriate standard of care forthe delivery of quality medical services to Patient C for reasonsincluding, but not lim ited to the follow ing:

a. The R espondent's docum entation is deficient. H is notes of PatientC 's h is to ry , p hy sic al e xaminatio ns , tre atment p la n and ra tio na le a reinadequate to support his chronic prescription of Percocet toPatient C . The peer reviewers noted that they did not find neitherthe consulting urologist or gynecologist reported that Patient C wassuffering from chronic pelvic pain, nor was there any indication inthe record that there was a physiological basis for her complaints;

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b. The Respondent treated Patient C 's complaints of pain w ithnarcotics only; and

c. Failure to date prescriptions for Schedule II CDS is a violation offede ra l and s ta te regu la tions

Patien t D44. Patient D, a female born in 1953, initia lly presented to the

Respondent in or around 1983. The Respondent's progress notesp rior to th e review pe riod in dica te tha t P atie nt D be gan complain in gof back pain in January 1999 and that the Respondent beganprescrib ing Percocet to Patient D at that time. The reafte r, th eR espondent treated Patient D on a m onthly basis and continued toprescribe O xycontin and P ercocet at every visit. In February 1999,the R espondent added Tranxene to P atient D 's m edication regim e.In April 1999, the R espondent began prescrib ing O xycontin 10 m gevery tw elve (12) hours rather than Percocet.

45. On July 30, the Respondent increased the dosage of Oxycontin to40 mg and prescribed Oxycontin, Percocet and Tranxene to Patient0 at each of her m onthly office visits.

46. In N ovember 1999, P atient 0 underw ent a lum bar interbody fusion.By February 2000, Patient D reported w orsening back pain and theRespondent diagnosed her with "fa iled back syndrome." Heincreased the dosage of Oxycontin to 80 mg, the maximum unitdosage.

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47.

48.

49.

50.

O n June 23, 2001, Patient D underwent surgical fusion of L4 to L5and a d iskectomy.On August 6, 2001, the neurosurgeon who had conducted thesurgery reported to the Respondent that Patient D was doing welland that her use of analgesics had decreased.The R espondent continued to prescribe O xycontin 80 mg, P ercocetand Tranxene to Patient D subsequent to receipt of the post-operative reports.The R espondent failed to m eet the standard of care for the deliveryof quality m edical services to Patient D for reasons including, butnot lim ited to , the fo llow ing:a. The Respondent's documentation is deficient. H is notes ofPatient D 's history, physical exam inations, treatment plan andra tion ale a re in ad eq uate to su ppo rt e ithe r h is ch ro nic p re scrip tio n o fmultip le narcotics such as Percocet and Oxycontin to Patient D orthe quantities in which he prescribed them ;b. The Respondent did not document his rationale formaintaining Patient D 's medications at the same level follow ing areport that her pain was im proving and that her use of narcotics haddecreased;c. The Respondent failed to document the necessity ofprescrib ing T ranxene to P atient D on a chronic basis; and

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d. The Respondent failed to document the medical necessity ofprescrib ing a benzodiazepene in conjunction w ith a Schedule IICDS.

Patient E52.

53.

54.

Patient E, a male born in 1969, in itially presented to theRespondent on April 14, 1998 w ith complaints of cervical spinepain. P atient E had sustained a motor vehicle accident in February1996 but had not sought treatment since that time. Patient E 'sprogress notes prior to the review period indicate that a PAexam ined Patient E and noted that he had decreased ROM in allplanes and pain on palpitation. The R espondent prescribedOxycontin 20 m g q 12 hours (#60). The Respondent also referredPatient E for a neurosurgical evaluation. In April 1998, aneurosurgeon exam ined Patient E 's cervical spine M RI and wasunable to find any evidence of overt disk herniation, diskdegenera tion, cen tra l s tenosis o r la te ra l fo ram inal s tenosis .In M ay 1998, Patient E was exam ined by a second neurosurgeonw hose report indicated that Patient E dem onstrated a decreasedrange of motion, but found no evidence of root compression or aspecific cerv ical d is c d isease .Patient E returned in September 1998 complaining of neck pain.The Respondent prescribed Oxycontin 20 mg #90 and Percocet#20. The Respondent also referred him to a neurosurgeon other

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55.

56.

57.

58.

59.

than the one who conducted the M ay 1998 evaluation. The secondneurosurgeon found "severe bilateral paraceNical spasms;"however, he was unable to find a focal neurological deficit orevidence of m yelopathy. The R espondent continued to prescribeO xycontin 20 mg (#90) and P ercocet (#20).On December 30, 1999, the Respondent added Tranxene toPatient E 's medication regime, noting that he was "upset &neNous."The Respondent continued to prescribe the combination ofO xycontin, P ercocet and Tranxene to P atient E through D ecember2000.On January 27, 2000, the Respondent increased the dosage ofOxycontin from 20 mg to 40 mg. He indicated that Patient E haddecreased ROM .On November 2, 2000, the Respondent prescribed Oxycontin,Percocet, Tranxene and Librax, a benzodiazepine, to Patient E.The Respondent failed to document his treatment rationale forprescrib ing 2 benzodiazepines in conjunction w ith 2 Schedule IICDS to Patient E, nor did he document that he warned Patient E ofthe possible soporific effects of these m edications.During the review period, the Respondent increased the number ofOxycontin and Percocet tablets he prescribed to Patient E w ithoutdocum enting the reason.

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60. T he R espondent failed to m eet the standard of care for the deliveryof quality m edical services to P atient E for reasons including, butn ot lim ite d to th e fo llo win g:

a. The R espondent's docum entation is deficient. H is notes of P atientE's history, physical exam inations, treatm ent plan and rationale areinadequate to support either his chronic prescription of m ultip lenarcotics such as Percocet and O xycontin to Patient E or thequantities in w hich he prescribed them .

b. The R espondent failed to docum ent the treatm ent rationale forincreasing the dosage of O xycontin and Percocet;

c. The R espondent failed to docum ent the treatm ent rationale forprescrib ing then discontinuing a benzodiazepine to P atient E andfurther failed to docum ent the treatm ent rationale for prescribingtw o (2) benzodiazepines in conjunction w ith tw o (2) narcoticanalgesics.

CONCLUSIONS OF LAWB ased on the foregoing Findings of F act, the B oard concludes as a

m atter of law that the R espondent's actions constitute im m oral orunprofessional conduct in the practice of m edicine, in violation of H .O . 14-404(a)(3); a violation of the appropriate standard of care for thedelivery of quality m edical services, in violation of H .O . 14-404(a)(22)a nd fa ilu re to m ain ta in a de qu ate m ed ic al re co rd s, in v io la tio n of H.O. 14-404(a)(40).

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ORDERBased on fore~~g Findings of Fact and Conclusions of Law, it is

this .2 t lLday of .';'r-j-(~._,.

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b. W ithin one (1) year of the date of this C onsent O rder, theR espondent's practice shall undergo a peer review by an appropriate peerreview entity and the results of th is peer review shall be satisfactory in thejudgm ent of the B oard; and it is further

ORDERED that any violation of the term s and/or conditions of th isO rder shall be deem ed a violation of probation and/or this C onsent O rder;and it is further

ORDERED that the R espondent shall com ply w ith the M arylandM edical P ractice A ct and all law s, statutes and regulations pertain ing toth e pra ctice of m ed icin e; a nd it is fu rth er

ORDERED that if the R espondent vio lates any of the term s andconditions of this probation and/or this C onsent O rder, the Board, in itsdiscretion, after notice and an opportunity for a hearing m ay im poseadditional sanctions under 14-404(a) and 14-405.1 of the M edicalP ractice A ct, including a reprim and, probation, suspension, revocationand/or a m onetary fine, said violation being proved by a preponderance ofthe evidence; and it is further

ORDERED that the R espondent shall not petition the B oard forearly term ination of the term s and conditions of th is C onsent O rder; and itis f ur th e r

ORDERED that the R espondent m ay petition for term ination ofprobationary status w ithout any further conditions or restrictions only if the

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R es po nd en t h as s atis fa cto rily c om p lie d w ith a ll c on ditio ns o f p ro ba tio n a ndha s no ou tstan din g co mpla in ts; a nd it is furthe r

ORDERED th at th e R esp on den t is re spo nsib le fo r a ll co sts in cu rre din fulfillin g th e te rm s an d co nd ition s o f th is C on se nt O rd er; an d it is fu rth er

ORDERED that th is Consent Order shall be a PUBLICDOCUMENT pursuant to M d. S tate Gov't Code Ann. 10-611 et seq.(1999).

I' \.\\ '\; - - - ~. . r, . f - , ",,'

\ Z:v : I- :>Date: ~

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CONSENTI, Marc S. Posner, MD., acknow ledge that I am represented by counsel

and have consulted w ith counsel before entering this Consent O rder. By thisC onsent and for the purpose of resolving the issues raised by the Board, I adm itto these allegations, and I agree and accept to be bound by the foregoingC onsent O rder and its conditions.

I acknow ledge the valid ity of th is C onsent O rder as if entered into after theconclusion of a form al evidentiary hearing in which I w ould have had the right tocounsel, to confront w itnesses, to give testim ony, to call w itnesses on m y ownbehalf, and to all other substantive and procedural protections provided by thelaw. If a hearing had been held in this case, I would have produced experttestimony from a specialist in pain management who would testify that my care ofthe subject patients w as appropriate. I agree to forego my opportunity tochallenge these a llegat ions. I acknowledge the legal authority and jurisdiction ofthe Board to initiate these proceedings and to issue and enforce this ConsentOrder. I affirm that I am waiving my right to appeal any adverse ruling of theB oard that I m ight have follow ed after any such hearing.

I s ign this Consent Order after having an opportunity to consult w ithcounsel, voluntarily and w ithout reservation, and I fully understand andcomprehend the language, m eaning and term s of the C onsent O rder.

I/,P"~< i '- -,"___3

Date Marc S . P osner, M .D .Respondent

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STATE OF MARYLANDC ITY /COUNTY OF /;';, yif., ,/ ;'

I HEREBY CERTIFY that on this day of January 2005, before me,a Notary Public of the foregoing State and City/County personally appearedMarc S. Posner, M .D., License Number D19640, and made oath in due form oflaw that signing the foregoing C onsent O rder w as his voluntary act and deed.

AS W ITNESSETH m y hand and notaria l seal.

; ,(.;' , / ~ic..' , 'Nota ry P ub lic