Page 1 of 6 Application - Physician/Surgeon 4/20/2021 https://www

Application - Physician/Surgeon

Name JAMIE PHIFER

Credential Physician/Surgeon

Fee Details

Fee to Query NPDB $4.75

Initial Application Fee $565.00

$569.75

Past Connecticut Licensure/Certification

Please do not complete this application if you currently hold or have held a CT license/certificate for this profession.

This application is for individuals APPLYING for a license/certificate for the FIRST TIME. It is not for applicants who are attempting

to renew a license/certificate or to reinstate a lapsed license/certificate.

If you are trying to renew a license/certificate and do not have your assigned user ID and password, please DO NOT CONTINUE

with this application.

Please email oplc.[email protected] and include, for your protection, your name, profession, date of birth and the last four digits of your

Social Security number and your user ID and password will be emailed to you.

Please note that not all profession types allow for online renewal at this time.

To continue this application, select the 'Next' button at the bottom left corner of the screen.

Application Instructions

Thank you for applying for your license online. Please note that as part of this application, you will be required to upload a recent

picture of yourself. Please make sure you have one available on the device you are using to file this application.

Please be advised that application fees submitted to the department are non-refundable.

Please note that you need to arrange for the submission, directly from the source, of a transcript from your medical school,

verification of at least 2 years of progressive, post graduate residency training, verification of completion of the required

examinations and verification of all licenses held, current or expired.

Applicants who completed medical school outside of the United States are required to arrange for their medical school to send a

completed school verification form and a transcript directly to this office verifying completion of medical school. Non-US trained

applicants are also required to arrange for the submission of verification of current certification by ECFMG.

For detailed information regarding eligibility and documentation requirements, please visit www.ct.gov/dph/license and select

Physician/Surgeon.

As part of this application, you will provide information that will be used to create a profile that will be published on the

Department's website. Following issuance of licensure, you will be provided with an opportunity to review and update the profile

prior to its publication.

APPLICANTS WHO HAVE HELD A CT PHYSICIAN LICENSE IN THE PAST SHOULD NOT USE THIS SERVICE TO APPLY

FOR REINSTATEMENT.

Demographic Information - Initial Application

1. Maiden Name

2. Please provide your Date of Birth

08/25/1985

3. U.S. Social Security Number

**********

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4. Gender

Female

5. Ethnicity: Please choose one

Not Hispanic or Latino

6. Race:

White

7. Please attach a recent photo of the applicant.

Basis of Licensure

Please select a basis for licensure.

Please note the following definitions:

Endorsement: Select this basis of licensure if you were educated in the United States and are, or have been, licensed in any other

U.S. state or Canadian province.

Endorsement - FT: Select this basis of licensure if you completed your educational preparation outside of the U.S. and you are, or

have been, licensed in any U.S. state or Canadian province.

Exam: Select this basis of licensure if you were educated in the U.S. and this is the first time you are applying for a license in any

jurisdiction.

Exam - FT: Select this basis of licensure if you completed your educational preparation outside of the U.S. and this is the first time

you are applying for a license in any jurisdiction.

8. Select Basis for Licensure

Endorsement

Federation Credentials Verification Service (FCVS)

FCVS obtains primary-source verification of medical education, postgraduate training, examination history, board action history,

board certification and identity. This repository of information allows a physician and/or physician assistant to establish a

confidential, lifetime professional portfolio with FCVS which can be forwarded, at the applicant's request, to any state medical and

osteopathic board that has established an agreement with FCVS. Please note that this is optional.

9. If you plan to use the Federation Credentials Verification Service (FCVS) to verify your core credentials, enter your FCVS

Packet ID here

215785155

Medical Education

10. Medical School

UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE

11. Year of Graduation

2011

Post Graduate Training Information

Please enter any internship, residency or fellowship training you have completed

12. List your postgraduate training:

Site Name City State Country Start Date End Date Level Type

SWEDISH CHERRY HILL FAMILY MEDICINE

RESIDENCY

SEATTLE Washington UNITED

STATES

06/21/2011 06/24/2014 Resident

National Provider Identifier

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The National Provider Identifier (NPI) is a 10-digit identifier required on all HIPAA standard electronic transactions. NPIs have

replaced all separately issued identifiers, including Medicaid PINs and Medicare UPINs, on HIPAA standard electronic

transactions. In the past, health plans assigned an identifying number to each provider with whom they conducted electronic

business. Since providers typically work with several health plans, they were likely to have a different identification number for

each plan. The NPI has been put in place so that each provider has one unique, United States federal government-issued

identifier to be used in transactions with all health plans with which the provider conducts business.

13. Please enter your NPI number here (if you do not know your NPI number, you may retrieve it at

https://npiregistry.cms.hhs.gov.) If you do not have an NPI number, please enter ten (10) zeros):

1154615185

Specialty/Board Certification

Please enter your specialty, subspecialty and indicate the date on which you were certified by an ABMS ABMOS specialty board

14. Please indicate practice specialties, subspecialties and the date you were certified by ABMS or ABOMS, if applicable. Board

certification is not a requirement for licensure.

Specialty Subspecialty Certifying Board Certification Date

Family Medicine

Subspecialty Certification Date

American Board of Family Medicine 06/25/2014

Other State License

15. Indicate states outside of CT where licenses are held, current or expired

State Disciplinary Action

Washington No

Florida No

Kansas No

Maryland No

New Jersey No

Illinois No

Massachusetts No

Current Practice Information

16. Upon issuance of your Connecticut license, will you practice medicine in Connecticut?

Yes

17. Are you actively involved in patient care?

Yes

18. Enter your practice locations

Practice

Name

Address 1 Address

Address

City State Zip

Code

Primary

Practice

Languages Spoken at

this Location

Swedish

Medical Group

600 University

Street #1200

Seattle Washington 98101 No

98point6 701 5th Ave STE

2300

Seattle Washington 98104 Yes

Connecticut Hospitals and Nursing Home Privileges

Please enter the Connecticut hospitals and nursing homes where you will have admitting privileges

19. Indicate the Connecticut hospitals or nursing homes for which you have or will have staff privileges

Facility Name City State

Medical Education Responsibilities

20. Are you a member of the faculty of a Connecticut medical school?

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21. Select the state medical schools at which you are a member of the faculty.

22. Do you have current responsibility for graduate medical education?

Statement of Professional History

Please answer the following questions. If you answer yes to any of the questions regarding your professional history, please

provide details in the space available below and arrange for the submission of supporting documentation (e.g. certified court copy

with court seal affixed, complaint, answer, judgment, settlement or disposition) that will assist this office’s review. Applicant's

answering affirmatively to any question below may be contacted for additional information.

23. Have you ever been censured, disciplined, dismissed or expelled from, had admissions monitored or restricted, had

privileges limited, suspended or terminated, been put on probation, or been requested to resign or withdraw from any of the

following: Any hospital, nursing home, clinic, or similar institution; Any health maintenance organization, professional partnership,

corporation, or similar health practice organization, either private or public; Any professional school, clinical clerkship, internship,

externship, preceptorship; or postgraduate training program; Any third party reimbursement program, whether governmental or

private?

24. Have you ever had your membership in or certification by any professional society or association suspended or revoked for

reasons related to professional practice?

25. Has any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or

territory, or a foreign jurisdiction, limited, restricted, suspended or revoked any professional license, certificate, or registration

granted to you, or imposed a fine or reprimand, or taken any other disciplinary action against you?

26. Have you ever entered into, or do you currently have pending, a consent agreement of any kind, whether oral or written, with

any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, any

branch of the armed services or a foreign jurisdiction?

27. Have you ever, in anticipation or during the pendency of an investigation or other disciplinary proceeding, voluntarily

surrendered any professional license, certificate or registration issued to you by any state, the District of Columbia, a United

States possession or territory, or a foreign jurisdiction?

28. Have you ever been subject to, or do you currently have pending, any complaint, investigation, charge, or disciplinary action

by any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or

a foreign jurisdiction or any disciplinary board/committee of any branch of the armed services? You need not report any

complaints dismissed as without merit?

29. Have you ever been found guilty or convicted as a result of an act which constitutes a felony under the laws of this state,

federal law or the laws of another jurisdiction and which, if committed within this state, would have constituted a felony under the

laws of this state?

30. Provide details regarding any question(s) above that you may have answered affirmatively.

Medical Malpractice Payment History

Please indicate below any malpractice payments that you have made or have been made on your behalf during the ten (10) year

period immediately preceding the date of this application

31. Indicate your malpractice insurance carrier:

32. Indicate the medical malpractice payments that have been made by you or on your behalf within the past ten years.

Resolved Date Payment Category Amount Paid Specialty Group Count Payment Count

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Felon

Conviction Histor

Please list any felony that you have been convicted of during the ten (10) year period immediately preceding the date of this

application

33. Please enter any felony convictions within the previous ten years.

Conviction Date Conviction

Hospital Discipline

Please list any disciplinary action taken against you by a hospital during the ten (10) year period immediately preceding the date of

this application

34. Please enter any felony convictions within the previous ten years.

Conviction Date Conviction

Publications, Services or Awards

Please indicate any publications, services or awards (this section is voluntary)

35. In this section, you may add any publications, professional services, activities, and awards that you would think useful to

viewers of your profile.

Publisher/Issuer Title/Award Name Date

Application Attestation

36. By filing this application online on the date indicated below, I attest that I am the person referred to in this application and that

the photograph attached hereto is a true picture of me and that the statements made herein are true in every respect.

11/08/2019

American Medical Association's Opinions

The Connecticut Medical Examining Board and the Connecticut Department of Public Health encourage you to read the following

opinions of the American Medical Association's Code of Medical Ethics related to common reasons for discipline on Connecticut

physicians licenses.

AMA Code of Ethics

Opinion 1.2.1 Treating Self or Family

Treating oneself or a member of ones own family poses several challenges for physicians, including concerns about professional

objectivity, patient autonomy, and informed consent.

When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional

medical judgment. Or the physician may fail to probe sensitive areas when taking the medical history or to perform intimate parts

of the physical examination. Physicians may feel obligated to provide care for family members despite feeling uncomfortable doing

so. They may also be inclined to treat problems that are beyond their expertise or training.

Similarly, patients may feel uncomfortable receiving care from a family member. A patient may be reluctant to disclose sensitive

information or undergo an intimate examination when the physician is an immediate family member. This discomfort may

particularly be the case when the patient is a minor child, who may not feel free to refuse care from a parent.

In general, physicians should not treat themselves or members of their own families. However, it may be acceptable to do so in

limited circumstances:

(a) In emergency settings or isolated settings where there is no other qualified physician available. In such situations, physicians

should not hesitate to treat themselves or family members until another physician becomes available.

(b) For short-term, minor problems.

When treating self or family members, physicians have a further responsibility to:

(d) Recognize that if tensions develop in the professional relationship with a family member, perhaps as a result of a negative

medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.

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(e) Avoid providing sensitive or intimate care especially for a minor patient who is uncomfortable being treated by a family

member.

(f) Recognize that family members may be reluctant to state their preference for another physician or decline a recommendation

for fear of offending the physician.

AMA Principles of Medical Ethics

Opinion 9.1.1 Romantic or Sexual Relationships wth Patients

Romantic or sexual interactions between physicians and patients that occur concurrently with the patient physician relationship are

unethical. Such interactions detract from the goals of the patient-physician relationship and may exploit the vulnerability of the

patient, compromise the physician’s ability to make objective judgments about the patient’s health care, and ultimately be

detrimental to the patient’s well-being.

A physician must terminate the patient-physician relationship before initiating a dating, romantic, or sexual relationship with a

patient.

Likewise, sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous

physician-patient relationship. Sexual or romantic relationships with former patients are unethical if the physician uses or exploits

trust, knowledge, emotions, or influence derived from the previous professional relationship, or if a romantic relationship would

otherwise foreseeably harm the individual.

In keeping with a physician’s ethical obligations to avoid inappropriate behavior, a physician who has reason to believe that

nonsexual, nonclinical contact with a patient may be perceived as or may lead to romantic or sexual contact should avoid such

contact.

Review

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Practitioner Profile for JAMIE PHIFER, 1.064692 view pub update online

Practitioner Profile Status

Prepublication Status None

Publication Status Published

Pending Updates NO

1. Physician Information update

License Number 64692

Effective Date 12/20/2019

Expiration Date 08/31/2021

Currently practicing medicine in CT YES

Actively involved in patient care YES

Practice Locations add

Practice Address Languages Primary?

update 98point6 701 5th Ave STE 2300

Seattle, WA 98104

YES

update Swedish Medical Group 600 University Street #1200

Seattle, WA 98101

Staff Privileges add

Facility Address Start Date End Date

2. Medical School update

Medical School UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE

Year of Graduation 2011

3. Post Graduate Training add

Start End Type Level Hospital Address

update 06/21/2011 06/24/2014 Resident SWEDISH CHERRY HILL FAMILY

MEDICINE RESIDENCY

SEATTLE,

UNITED

STATES

4. Specialty Area and Board Certification add

Specialty/Subspecialty Board Cert Date Speciality End Date Certifying Board

update Family Medicine add

sub

06/25/2014 American Board of Family Medicine

5. CT Medical Education Responsibility update

Member of faculty of a CT medical school NO

Medical School

Current Responsibility for graduate medical education NO

6. Publications, Professional Services, Activities, Awards add

Publisher/Issuer Title/Award Name Date

7. Hospital Discipline add

Hospital Address Date Discipline

8. Medical Malpractice Payments add dispute

Payment Date Payment Category Amount Paid Related Practice Specialty

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9. Felony Convictions add dispute

Date of Conviction Conviction

10. CT Licensure Disciplinary Actions dispute

Date of Action Action License Status

Page 2 of 2Practitioner Profile for JAMIE PHIFER, 1.06469

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Renewal - 1.064692

Name JAMIE PHIFER

Credential 1.064692

Fee Details

Renewal Fee $575.00

$575.00

Workforce Survey Introduction

Dear Licensee:

Thank you for renewing your license online.

As part of this renewal application, you will be asked to enter your National Provider Identification (NPI) number. Please

make sure you have that information available before proceeding. If you do not have your NPI number with you, you can

find it online at https://npiregistry.cms.hhs.gov/. You will also be asked to enter information regarding your practice

location, specialty and patients served.

The purpose of the questions is to allow the Department of Public Health to collect valuable workforce and patient care

data that is critical in identifying and addressing healthcare workforce shortage and patient care issues.

Thank you for assisting the Department in this important initiative.

Demographic Information-Renewal

1. Please provide your Date of Birth

08/25/1985

2. Gender

Female

3. Ethnicity: Please choose one

Not Hispanic or Latino

4. Race:

White

Address

Please be advised that all information provided by licensees and applicants, excluding Social Security Numbers and including

addresses and phone numbers, is public information and is releasable pursuant to the Freedom of Information Act.

5. Please update any changes to your mailing address:

Address 1: 1037 NE 65TH ST # 371

Address 2:

City: SEATTLE State: WA Zip Code: 98115-

6655

Country: UNITED

STATES

6. Please update any changes to your primary address:

Address 1: 1037 NE 65TH ST # 371

Address 2:

City: SEATTLE State: WA Zip Code: 98115-

6655

Country: UNITED

STATES

Telephone Number: (206) 743-7791

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Email Address Verification

Please be advised that the Department no longer mails hardcopy licenses and renewal notices. Rather, licenses and renewal

notices will be sent via email. You will receive an electronic copy of your license via email within a few days of completing this

transaction. Renewal notices will be sent via email approximately 60 days prior to your license expiration date.

Residence Address

Please enter the information below regarding the address of your residence. Please note that entering your address here will not

change your mailing address in our system. If you have a change of address, please email it to o[email protected]. For your

protection, please include your profession, license number and the last 4 digits of your SSN in your request.

7. Street Address

3020 S Adams St

8. Unit/Apartment Number

9. City

Seattle

10. State (two letter abbreviation)

11. Zip Code

98108

Medical Education

12. Medical School

UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE

13. Year of Graduation

2011

Specialty/Board Certification

14. Please indicate practice specialties, subspecialties and the date you were certified by ABMS or ABOMS, if applicable. Board

certification is not a requirement for licensure.

Specialty Subspecialty Certifying Board Certification Date

Family Medicine

Subspecialty Certification Date

American Board of Family Medicine 06/25/2014

Current Workforce Status in Medicine

15. What is your current work status in medicine?

Full Time - (40 hours or more per week)

16. In the next 12 months, do you plan to (please mark all that apply):

None

17. If 100% of your primary professional position is not direct patient care, please indicate which of the following apply:

18. If your response to the previous question was other, please enter additional comments here.

National Provider Identifier

The National Provider Identifier (NPI) is a 10-digit identifier required on all HIPAA standard electronic transactions. NPIs have

replaced all separately issued identifiers, including Medicaid PINs and Medicare UPINs, on HIPAA standard electronic

transactions. In the past, health plans assigned an identifying number to each provider with whom they conducted electronic

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business. Since providers typically work with several health plans, they were likely to have a different identification number for

each plan. The NPI has been put in place so that each provider has one unique, United States federal government-issued

identifier to be used in transactions with all health plans with which the provider conducts business.

19. Please enter your NPI number here (if you do not know your NPI number, you may retrieve it at

https://npiregistry.cms.hhs.gov.) If you do not have an NPI number, please enter ten (10) zeros):

1154615185

Professional Liability Insurance

Your professional practice act requires that a practitioner providing direct patient care services must maintain professional liability

insurance or other indemnity against liability for professional malpractice. You may find information regarding professional liability

insurance requirements by selecting this link and choosing your profession from the list.

Physician Renewal Practice Location

20. Please indicate the name and address of your primary practice location as well as languages spoken at that location. Please

note that you can add additional practice locations but you may only select one (1) primary practice location.

Practice

Name

Address 1 Address

Address

City State Zip

Code

Primary

Practice

Languages Spoken at

this Location

98point6 701 5th Ave STE

2300

Seattle Washington 98104 Yes

Swedish

Medical Group

600 University

Street #1200

Seattle Washington 98101 No

21. Approximately how many physicians are associated with your practice (If you are in residency training, please enter zero (0)

here)?

22. Is the primary site where you spend most time providing direct patient care a JCAHO/NCQA recognized patient care

centered medical home?

23. Please select the best choice for the type of ownership of your practice.

Other corporation

Practice Ownership - Organization

24. Please enter the name of the organization/person that owns the practice where you work.

98point6

25. City

Seattle

26. State (two letter abbreviation)

New Patients

27. Please select the best response that describes your patient care practice status:

I can accept some new patients; my practice is far from full

28. Are you accepting new patients covered by:

Neither

Primary Source of Payment

Please answer the questions to the best of your ability. If you do not know the exact amount, please select the answer that you

think is correct. This information is used by the Department to analyze current trends in the practice of medicine in Connecticut

and is not used in any way to determine your eligibility for license renewal.

What percent of your patients have the following source of payment?

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29. Medicare

None

30. Medicaid

None

31. Self-Pay

26 - 50%

32. Private Insurance

76 - 100%

33. Other

less than 10%

34. Does your practice offer sliding fee scale based on ability to pay?

35. Approximately what percentage of your patients use sliding fee schedules?

None

Populations Served

Please answer the questions to the best of your ability. If you do not know the exact amount, please select the answer that you

think is correct. This information is used by the Department to analyze current trends in the practice of medicine in Connecticut

and is not used in any way to determine your eligibility for license renewal.

Please approximate the percentage of patients at your primary practice location that are:

36. Homeless

Less than 10%

37. Migrant/Seasonal Farm Workers

Less than 10%

38. Native Americans

Less than 10%

Connecticut Prescription Monitoring and Reporting System

All prescribing practitioners possessing a Connecticut controlled substance registration (CSP) issued by the Connecticut

Department of Consumer Protection (DCP) must register with the Connecticut Prescription Monitoring and Reporting System

(CPMRS) online at www.ctpmp.com.

After you have completed this renewal transaction, please visit the DCP's website at www.ct.gov/dcp and select 'Programs &

Services' then 'Prescription Monitoring Program' for information regarding registration.

39. I acknowledge that I have read the information regarding registration in the Connecticut Prescription Monitoring and

Reporting System.

08/28/2020

Physician Attestation

40. Since your last renewal, have you been convicted of a felony?

41. If yes, please provide details here

42. Since your last renewal, have you had any disciplinary action taken against you or any such actions pending by any State,

federal government jurisdiction, District of Columbia, United States possession or territory or foreign jurisdictions

licensing/certification authority?

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43. If yes, please provide details here

44. I attest that I am in compliance with the mandatory continuing education requirements and that I am in compliance with the

mandatory professional liability insurance coverage requirements.

45. I attest that on this date I completed this renewal application online and that all of the statements made by me on this

renewal are accurate.