ACCEPTED 15-25-00036-CV FIFTEENTH COURT OF APPEALS AUSTIN, TEXAS 9/29/2025 11:34 AM CASE NO. 15-25-00036-CV CHRISTOPHER A. PRINE __________________________________________________________________ CLERK FILED IN 15th COURT OF APPEALS IN THE COURT OF APPEALS AUSTIN, TEXAS FOR THE FIFTEENTH DISTRICT OF TEXAS AT AUSTIN 9/29/2025 11:34:23 AM __________________________________________________________________ CHRISTOPHER A. PRINE Clerk

JORGE R. GUEVARA, M.D., Appellant, v. TEXAS MEDICAL BOARD, Appellee.

APPELLEE TEXAS MEDICAL BOARD’S BRIEF

KEN PAXTON KATHY JOHNSON Attorney General of Texas State Bar No. 24126964 Assistant Attorney General BRENT WEBSTER Ted A. Ross First Assistant Attorney General Assistant Attorney General State Bar No. 24008890 RALPH MOLINA Administrative Law Division Deputy First Assistant Attorney Office of the Attorney General of Texas General P.O. Box 12548, Capitol Station Austin, Texas 78711-2548 AUSTIN KINGHORN Telephone: (512) 475-4164 Deputy Attorney General for Civil Facsimile: (512) 320-0167 Litigation [email protected] [email protected] ERNEST C. GARCIA Chief, Administrative Law ATTORNEYS FOR APPELLEE Division TEXAS MEDICAL BOARD

ORAL ARGUMENT NOT REQUESTED

TABLE OF CONTENTS

INDEX OF AUTHORITIES ..................................................................... 4

IDENTITY OF PARTIES & COUNSEL .................................................. 7

REFERENCES ......................................................................................... 8

STATEMENT REGARDING ORAL ARGUMENT .................................. 9

ISSUES PRESENTED ............................................................................ 10

STATEMENT OF FACTS ....................................................................... 11

SUMMARY OF THE ARGUMENT ....................................................... 14

STANDARD OF REVIEW ...................................................................... 15

ARGUMENT ........................................................................................... 18

I. The trial court correctly affirmed TMB’s Final Order, finding that TMB did not exceed its statutory authority in disciplining Dr. Guevara............................................................ 18

II. Substantial evidence supports the findings of violation TMB found in its Final Order. ....................................................... 23

A. Dr. Guevara failed to ensure that MAB established and maintained a quality assurance and control program ................................................................................. 26

B. Dr. Guevara failed to ensure that MAB employed qualified personnel to perform mammography imaging .................................................................................. 28

C. Dr. Guevara failed to ensure that MAB provided the results of the mammography reports to each of his patients ............................................................................ 30

APPELLEE’S BRIEF Page 2 of 41

III. The trial court correctly affirmed TMB’s Final Order because it was not arbitrary nor capricious when it reached a reasonable result. .......................................................... 31

CONCLUSION ........................................................................................ 38

CERTIFICATE OF COMPLIANCE ........................................................ 40

CERTIFICATE OF SERVICE................................................................. 40

APPENDICES ......................................................................................... 41

APPELLEE’S BRIEF Page 3 of 41

INDEX OF AUTHORITIES

Cases Aleman v. Tex. Med. Bd., 573 S.W.3d 796 (Tex. 2019) ...................................................... 20, 21, 22

Anderson-Clayton Bros. Funeral Home, Inc. v. Strayhorn, 149 S.W.3d 166 (Tex. App.—Austin 2004, pet. denied) ................. 17, 18

Bd. of Law Exam’rs v. Stevens, 868 S.W.2d 773 (Tex. 1994) ...................................................... 16, 17, 35

City of El Paso v. Pub. Util. Comm’n, 883 S.W.2d 179 (Tex. 1994) .................................................................. 33

Lane v. Tex. Med. Bd., No. 03-21-00593-CV, 2023 WL 4214945 (Tex. App.—Austin June 28, 2023, pet. denied) (mem. op.) ........................................... 21, 23

R.R. Comm’n v. Tex. Citizens for a Safe Future & Clean Water, 336 S.W.3d 619 (Tex. 2011) .................................................................. 17

Scally v. Tex. State Bd. of Med. Exam’rs, 351 S.W.3d 434 (Tex. App.—Austin, 2011) (pet. denied) ............... 15, 16

Sergeant Enter., Inc. v. Strayhorn, 112 S.W.3d 241 (Tex. App.—Austin 2003, no pet.) .............................. 17

State v. Pub. Util. Comm’n, 883 S.W.2d 190 (Tex. 1994) .................................................................. 16

Tex. State. Bd. of Med. Exam’rs v. Birenbaum, 891 S.W.2d 333 (Tex. App.—Austin 1995, writ denied) ...................... 17

Statutes Tex. Gov’t Code § 2001.174 ............................................................................................. 15 § 2001.174(2)(A) .................................................................................... 16

APPELLEE’S BRIEF Page 4 of 41

§ 2001.1721(a) ....................................................................................... 18 § 2001.1721(b) ................................................................................. 18, 20

Tex. Health & Safety Code § 193.005(h) ........................................................................................... 20 § 401.422(a) ........................................................................................... 24 § 401.423(b) ........................................................................................... 24 § 401.424(a)(3)....................................................................................... 24 § 401.424(a)(4)(D).................................................................................. 24 § 401.426 ............................................................................................... 24

Tex. Occ. Code ch. 151 ................................................................................................... 15 § 151.001(4) ........................................................................................... 33 § 151.002(9) ........................................................................................... 21 § 151.002(13) ................................................................................... 19, 21 § 151.003 ............................................................................................... 33 § 164.001 ............................................................................................... 34 § 164.001(b)(3)....................................................................................... 34 § 164.001(e) ........................................................................................... 34 § 164.001(f) ............................................................................................ 34 § 164.051-.054 ....................................................................................... 34 § 164.051(a)(1)........................................................................... 18, 19, 37 § 164.052(a)(5)........................................................................... 18, 19, 37 § 164.053(a)(1)........................................................................... 18, 34, 37 § 164.053(a)(8)................................................................................. 19, 37 § 164.053(a)(9)................................................................................. 19, 37 § 601.002(6)-(7) ..................................................................................... 25

Rules 22 Tex. Admin. Code § 190.14(1) ....................................................................................... 34, 35 § 190.14(9) ....................................................................................... 35, 38 § 190.15 ................................................................................................. 35 § 190.15(a) ............................................................................................. 36

APPELLEE’S BRIEF Page 5 of 41

25 Tex. Admin. Code § 289 .................................................................................... 20, 24, 25, 26 § 289.226(n)(2) .......................................................................... 20, 25, 38 § 289.230 ............................................................................................... 25 § 289.230(r)(2) ........................................................................... 19, 20, 28 § 289.230(t)............................................................................................ 30 § 289.230(t)(1) ....................................................................................... 30 § 289.230(t)(2) ........................................................................... 19, 20, 30 § 289.230(u) ........................................................................................... 26 § 289.230(u)(1)(A).................................................................................. 26 § 289.230(u)-(w) ........................................................................ 19, 20, 26 § 289.230(v)(6) ....................................................................................... 27 § 289.230(v)(7) ....................................................................................... 26 § 289.230(v)(9)-(14) ............................................................................... 27 § 289.230(w) .......................................................................................... 27 § 289.234 ............................................................................................... 25

42 U.S.C. § 263b ...................................................................................... 24 42 U.S.C. § 263b(f) ................................................................................... 24 42 U.S.C. § 263b(m) ................................................................................. 24

Other Senate Bill 14 .......................................................................................... 18

APPELLEE’S BRIEF Page 6 of 41

IDENTITY OF PARTIES & COUNSEL

Parties

Appellant Jorge R. Guevara, M.D. Appellate Counsel: Jason Davis E-mail: [email protected] Hayley Ellison, Lead Counsel E-mail: [email protected] DAVIS & SANTOS, PLLC 719 S. Flores Street San Antonio, Texas 78204 Tel.: (210) 853-5882

Trial Counsel: John J. Rivas Ethan Yat Fai Lau RIVAS GOLDSTEIN, LLP

Appellee Texas Medical Board Appellee’s Trial and Appellate Counsel: Kathy Johnson Assistant Attorney General E-mail: [email protected] Ted Ross Assistant Attorney Geenral E-mail: [email protected] OFFICE OF THE ATTORNEY GENERAL P.O. Box 12548 Austin, Texas 78711 Tel.: (512) 475-4191

APPELLEE’S BRIEF Page 7 of 41

CITATION REFERENCES

Administrative Record A.R. at [TMB ###] Administrative Record

C.R. [page #]

Tr. [Page #: Line #]: SOAH contested case hearing transcript

Staff Ex. [#]: TMB Staff contested case hearing exhibits

App. Tab [#] Appendix attached to this brief

OTHER REFERENCES

ALJs The SOAH Administrative Law Judges

Dr. Guevara: Appellant, Jorge Guevara, M.D.

Final Order The TMB Final Order entered August 18, 2023

PFD The Administrative Law Judge’s Proposal for Decision signed on May 3, 2023

RSO Radiation Safety Officer

SOAH The State Office of Administrative Hearings

TMB: Appellee, Texas Medical Board

APPELLEE’S BRIEF Page 8 of 41

STATEMENT REGARDING ORAL ARGUMENT

The TMB does not request oral argument in this appeal because the factual issues are straightforward, and the legal issues have previously been addressed by the courts. However, the TMB requests the opportunity to participate if the Court sets oral argument.

APPELLEE’S BRIEF Page 9 of 41

ISSUES PRESENTED

1. Did the trial court err when it affirmed TMB’s Final Order finding that the TMB acted within its statutory authority when it disciplined Dr. Guevara?

2. Did the trial court err when it affirmed TMB’s Final Order finding that it was supported by substantial evidence when Dr. Guevara’s failures as a Radiation Safety Officer (RSO) were connected to his practice of medicine?

3. Did the trial court err when it affirmed TMB’s Final Order finding that TMB did not act arbitrarily or capriciously when it disciplined Dr. Guevara by barring Dr. Guevara from being associated with any imaging program, including owning, operating or acting as RSO for any imaging program?

APPELLEE’S BRIEF Page 10 of 41

STATEMENT OF FACTS

Dr. Guevara served as the radiation safety officer for his practice, Medical Associates of Brownsville (MAB). As the radiation safety officer

(RSO), Dr. Guevara had the responsibility to ensure that MAB personnel in the radiology department complied with all regulations and received adequate training. In January 2019, Department of State Health

Services (DSHS) conducted an investigation of MAB. The investigation revealed that MAB had failed to establish and maintain a mammography medical outcome program and failed to maintain a quality assurance program. A.R. at TMB1215. MAB had also hired unqualified mammography technicians, who had taken low quality mammography

images. DSHS reviewed a sample of MAB’s mammography images and found that 100% of the films were of poor quality, did not meet the standard of the accrediting body, and were of such poor quality that they did not reveal whether or not the patient had breast cancer. A.R. at

TMB1216.

After completing its investigation, DSHS brought an enforcement action against MAB at SOAH. 1 DSHS’s enforcement action against MAB

1 SOAH Docket Number XXX-XX-XXXX.

APPELLEE’S BRIEF Page 11 of 41

is not under judicial review in this case. As a result of its investigation, DSHS also referred Dr. Guevara, a licensed medical doctor, to the TMB for disciplinary action. The TMB pursued disciplinary action against Dr.

Guevara by filing a contested case at SOAH. A.R. at TMB1.

SOAH held a hearing on the merits on December 12, 2022. The Administrative Law Judge (ALJ) issued a Proposal for Decision (PFD) on

May 3, 2023. A.R. at TMB1146-1174. After both parties filed exceptions

and replies to certain findings of fact (FOF), the ALJ adopted all of the TMB’s exceptions on June 6, 2023. A.R. at TMB1170-73. The TMB then considered the ALJ’s Proposal for Decision and exceptions letter; TMB adopted all of the ALJ’s FOFs and conclusions of law (COLs) as identified in the PFD and exceptions letter. The TMB ultimately issued its Final

Order in SOAH Docket Number XXX-XX-XXXX on August 18, 2023. A.R. at

TMB1213-25.

The TMB Final Order states that Dr. Guevara:

1) shall not own, operate, act as radiation safety officer for, act as medical director for, or otherwise be associated with any imaging program including a program that performs mammography, and any facility where imaging studies, including but not limited to mammograms are performed or interpreted;

2) shall not perform any imaging services;

APPELLEE’S BRIEF Page 12 of 41

3) shall not supervise or delegate to any healthcare personnel engaged in the performance of imaging studies.

A.R. at TMB1220-21.

Dr. Guevara sought judicial review by filing Plaintiff’s Original

Petition, Ex Parte Application for Temporary Restraining Order and Temporary Injunction, and Request for Disclosure on October 12, 2023.

The trial court issued a Temporary Restraining Order regarding the TMB

Final Order. A Temporary Injunction Hearing took place on November

14, 2023. The Court denied Dr. Guevara’s request for a Temporary

Injunction on November 17, 2023. On December 6, 2023, Dr. Guevara perfected an interlocutory appeal of the court’s Order Denying Plaintiff’s

Application for Temporary Injunction. Subsequently, Dr. Guevara dismissed his appeal on January 8, 2024.

A hearing on the merits took place at the trial court on November

13, 2024. C.R. 379. Judge Connor signed the final judgment of the trial court on December 30, 2024, finding that TMB’s Final Order was supported by substantial evidence and that TMB acted within its statutory authority. C.R. 380. Dr. Guevara requested FOFs and COLs

APPELLEE’S BRIEF Page 13 of 41 from the trial court, which Judge Thomas 2 denied. C.R. 381-384. Dr.

Guevara filed a motion for new trial, which was overruled by operation of law. C.R. 385-390. Dr. Guevara then filed an appeal before this Court.

C.R. 392-393.

SUMMARY OF THE ARGUMENT

The Court should affirm the trial court’s final judgment affirming

TMB’s Final Order. TMB acted within its statutory authority when it disciplined Dr. Guevara by preventing him from being associated with any imaging program. Dr. Guevara’s failures as an RSO were connected to his practice of medicine and were likely to deceive or defraud the public because his dual role of physician and RSO implied to his patients that their mammography results were accurate. Substantial evidence supports TMB’s discipline of Dr. Guevara. He failed to ensure that MAB

1) established a quality assurance program; 2) hired qualified radiology techs; and 3) timely provided communication to mammography patients.

Despite these failures, Dr. Guevara repeatedly referred his patients to

MAB’s mammography facility. Finally, TMB’s Final Order is not

2Judge Thomas replaced Judge Connor in the 353rd Judicial District of Travis County while this case was still pending before the trial court.

APPELLEE’S BRIEF Page 14 of 41 arbitrary or capricious because it was tailored to address the risk that

Dr. Guevara poses to patients receiving imaging. TMB considered the factors the legislature instructed it to consider, did not consider irrelevant factors, and it reached a reasonable result. TMB employed its disciplinary matrix to discipline Dr. Guevara, determining that he should not be associated with any imaging service due to the risk he posed to patients and due to aggravating factors. For all of these reasons, TMB respectfully requests the Court to affirm the judgment below.

STANDARD OF REVIEW

The focus of the substantial evidence review is TMB’s Final Order.

Scally v. Tex. State Bd. of Med. Exam’rs, 351 S.W.3d 434, 441 (Tex.

App.—Austin, 2011, pet. denied); see Tex. Occ. Code ch. 151. Under the substantial evidence standard of review, a court may affirm an agency decision in whole or in part. Tex. Gov’t Code § 2001.174. The APA provides that an agency decision may be reversed or remanded for further proceedings:

[I]f substantial rights of the appellant have been prejudiced because the administrative findings, inferences, conclusions, or decisions are:

(A) in violation of a constitutional or statutory provision;

APPELLEE’S BRIEF Page 15 of 41

(B) in excess of the agency’s statutory authority; (C) made through unlawful procedure; (D) affected by other error of law; (E) not reasonably supported by substantial evidence considering the reliable and probative evidence in the record as a whole; or (F) arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.

Tex. Gov’t Code § 2001.174(2)(A). In reviewing TMB’s Final Order, it is

presumed that the order is supported by substantial evidence, and the Appellant bears the burden to prove otherwise. Scally, 351 S.W.3d at 441.

When applying the substantial evidence standard of review to the agency’s decision, the reviewing court is prohibited from substituting its own judgment for that of the agency as to the weight of the evidence on

questions committed to agency discretion. Bd. of Law Exam’rs v. Stevens, 868 S.W.2d 773, 778 (Tex. 1994). The test for review of an agency action is not whether the agency reached the correct conclusion, but whether some reasonable basis for the agency’s action exists in the record. State v. Pub. Util. Comm’n, 883 S.W.2d 190, 204 (Tex. 1994). Texas courts have

stated that although substantial evidence is more than a mere scintilla, the evidence may actually preponderate against the agency decision and yet still amount to substantial evidence supporting the result reached by

the agency. Id. at 204. If reasonable minds could have reached the APPELLEE’S BRIEF Page 16 of 41 conclusion that TMB reached on the record presented, then a court undertaking review should uphold the TMB Final Order. Stevens, 868

S.W.2d at 778; Tex. State. Bd. of Med. Exam’rs v. Birenbaum, 891 S.W.2d

333, 337 (Tex. App.—Austin, 1995, writ denied).

In reviewing questions of statutory construction, the courts give

“serious consideration” to an agency’s interpretation of a statute that it is charged with enforcing. R.R. Comm’n v. Tex. Citizens for a Safe Future

& Clean Water, 336 S.W.3d 619, 625 (Tex. 2011). “In ascertaining the scope of an agency’s authority, a reviewing court gives great weight to the contemporaneous construction of a statute by the administrative agency charged with its enforcement and recognizes that the legislature intends an agency created to centralize expertise in a certain regulatory area ‘be given a large degree of latitude in the methods it uses to

accomplish its regulatory function.’” Sergeant Enter., Inc. v. Strayhorn, 112 S.W.3d 241, 246 (Tex. App.—Austin 2003, no pet.). “If the agency’s

interpretation is consistent with the language and the purposes of the statute, the court will accept it, even if other reasonable interpretations exist.” Anderson-Clayton Bros. Funeral Home, Inc. v. Strayhorn, 149

APPELLEE’S BRIEF Page 17 of 41

S.W.3d 166, 178 (Tex. App.—Austin 2004, pet. denied). 3

The application of these standards mandates affirmance of the trial court’s judgment and the TMB Final Order.

ARGUMENT

I. The trial court correctly affirmed TMB’s Final Order, finding that TMB did not exceed its statutory authority in disciplining Dr. Guevara.

Dr. Guevara argues that TMB exceeded its statutory authority in disciplining Dr. Guevara (Appellant’s Br. at 19-26), but this argument fails. TMB acted within its statutory authority when it disciplined Dr.

Guevara by preventing him from being associated with any imaging practice because he engaged in unprofessional conduct in connection to his practice of medicine that was likely to deceive and defraud the public.

Tex. Occ. Code §§ 164.051(a)(1), .052(a)(5), .053(a)(1); A.R. at TMB1220.

3 Senate Bill 14, signed into law on April 25, 2025, and codified in Title A, Subchapter

G of the Government Code, amended the Administrative Procedure Act (APA) to explicitly state that Texas courts are not required to give deference to a state agency’s legal determination regarding the construction, validity, or applicability of the law or a rule. Tex. Gov’t Code § 2001.1721(a) (emphasis added). However, Courts are not prohibited from giving consideration to a state agency’s legal determination that is reasonable and does not conflict with the plain language of the statute. Tex. Gov’t Code § 2001.1721(b). Moreover, Senate Bill 14 does not change the well-settled standard of review of an agency’s determination of the weight of the evidence, as well as other presumptions in favor of an agency’s decision, in substantial evidence appeals under the APA.

APPELLEE’S BRIEF Page 18 of 41

Dr. Guevara engaged in such conduct by failing, as MAB’s RSO, to ensure that MAB 1) instituted a quality-assurance-and-control program; 2) hired qualified techs, and 3) timely provided communication to mammography patients. See 25 Tex. Admin. Code § 289.230(u)-(w), (r)(2), (t)(2). Dr.

Guevara also engaged in such conduct when he failed to adequately

supervise the activities of his employees. Tex. Occ. Code §§ 164.051(a)(1), .052(a)(5), .053(a)(8); A.R. at TMB1220. Furthermore, Dr. Guevara engaged in unprofessional conduct that was likely to deceive or defraud the public when he delegated professional medical responsibility to a person he knew or had reason to know was unqualified. Tex. Occ. Code

§§ 164.051(a)(1), .052(a)(5), .053(a)(9); A.R. at TMB1220.

The Medical Practice Act defines the practice of medicine as “the diagnosis, treatment, or offer to treat a mental or physical disease or disorder or a physical deformity or injury by any system or method, or the attempt to effect cures of those conditions, by a person who: a) publicly professes to be a physician or surgeon.” Tex. Occ. Code §

151.002(13).

While Dr. Guevara argues that his conduct as an RSO was not connected to his practice of medicine (Appellant’s Br. at 25), TMB

APPELLEE’S BRIEF Page 19 of 41 correctly determined that Dr. Guevara’s failure as an RSO is connected

to his practice of medicine. Dr. Guevara’s responsibilities as an RSO and physician overlapped. RSOs are required to “ensure that personnel are

adequately trained and complying with” the regulatory requirements in 25 Texas Administrative Code Chapter 289. 25 Tex. Admin. Code §

289.226(n)(2). Those requirements include ensuring that MAB instituted

a quality-assurance-and-control program, employed qualified techs, and sent out timely communications to patients. 25 Tex. Admin. Code §

289.230(u)-(w), (r)(2), (t)(2). The Court need not defer to TMB’s legal interpretation, but the Court may still give TMB’s interpretation due consideration. Tex. Gov’t Code § 2001.1721(b).

In Aleman, the court held that a “violat[ion] of state or federal law is subject to disciplinary action by the [TMB] under the Medical Practice

Act only if the act is connected with the practice of medicine in a manner that makes it likely to deceive or defraud the public.” Aleman v. Tex. Med.

Bd., 573 S.W.3d 796, 804 (Tex. 2019) (emphasis added). When TMB

sought to discipline Dr. Aleman for manually, instead of electronically, certifying a death certificate, in violation of the law4, the court found that

4 Texas Health and Safety Code 193.005(h) required physicians to electronically

APPELLEE’S BRIEF Page 20 of 41

this action, which did not involve the entry of inaccurate information, was not connected to his practice of medicine. Id. at 799, 805.

Significantly, however, Aleman noted that administrative tasks that are likely to deceive or defraud the public, such as providing inaccurate information on a death certificate, do rise to the level of activity connected to the practice of medicine. Id. at 808

In Lane, an unreported Third Court of Appeals opinion, that court

further elaborated upon the rule stated in Aleman. Lane v. Tex. Med. Bd., No. 03-21-00593-CV, 2023 WL 4214954, *8 (Tex. App.—Austin June 28, 2023, pet. denied). The court held that TMB did not err in concluding that

Dr. Lane’s conduct was connected to the practice of medicine when he failed to timely provide requested medical records. Lane, 2023 WL

4214954 at *8. The court found that failing to timely provide medical records was connected to the practice of medicine because it related to the treatment of the patient. Id. (citing Tex. Occ Code § 151.002(9), (13)).

The court also found that failing to timely provide the records may deceive or defraud the public by leading to improper treatment. Id.

Dr. Guevara’s failure to fulfill his duties as RSO is not merely an certify a death certificate.

APPELLEE’S BRIEF Page 21 of 41 administrative oversight as was Dr. Aleman’s failure to electronically certify a death certificate. Manually signing a death certificate does not cause harm to patients. However, Dr. Guevara’s failure as RSO to ensure that MAB followed the regulations for mammography providers likely harmed his patients. In Aleman, the court noted that providing inaccurate information on a death certificate would deceive and defraud the public. Aleman, 573 S.W.3d at 808. In this case, Dr. Guevara impliedly represented to his patients that MAB provided accurate mammography services by referring his own family-practice patients to

MAB’s mammography facility. But, without a quality-assurance-and- control program, qualified techs, or timely follow-up on results, MAB could not have provided accurate mammography services. See A.R. at

TMB1216.

Dr. Guevara referred 90-99% of the patients who used MAB’s mammography facility. A.R. Staff Ex. 42 at TMB1871 (84:04-84:06). Due

to his position of authority as his patients’ physician, his ownership of MAB, and his duty as RSO to ensure regulatory compliance, Dr. Guevara impliedly assured his patients of the reliability of MAB’s imaging services, even though he knew or was in a position to know otherwise.

APPELLEE’S BRIEF Page 22 of 41

Similar to Lane, Dr. Guevara did not provide his patients with critical treatment information.

While Dr. Lane did not send the requested patient records, Dr.

Guevara inaccurately represented the reliability of MAB’s mammography facility to his patients by referring them to the facility without ensuring that the facility had a quality-assurance-and-control program, qualified techs, or timely communication. See Tr. 34:09-34.16;

82:12-83.01; A.R. at TMB 2031, 2034-35, 2055, Staff Ex. 44. This behavior presented a risk to patients because Dr. Guevara, or another physician, may have relied upon MAB’s imaging even though it was of such poor quality that the images could not rule out breast cancer. A.R. at

TMB1216. This is exactly the type of administrative action that Lane declared is connected to the practice of medicine—actions that threaten the misdiagnosis or mistreatment of a patient. Lane v. Tex. Med. Bd., No.

03-21-00593-CV, 2023 WL 4214945, *8 (Tex. App.—Austin June 28, 2023, pet. denied). Dr. Guevara’s actions were likely to deceive and defraud the public.

II. Substantial evidence supports the findings of violation TMB found in its Final Order.

The federal law known as the Mammography Quality Standards

APPELLEE’S BRIEF Page 23 of 41

Act establishes national requirements for the certification of mammography providers. 42 U.S.C. § 263b. It requires facilities to meet certain quality standards, including standards requiring a facility to 1) establish and maintain a quality-assurance-and-control program; 2) to employ personnel who meet requirements to perform mammography; and 3) to provide a written report of the results of any mammography examination to each patient. 42 U.S.C. § 263b(f). The Mammography

Quality Standards Act does not limit the authority of any state to enact and enforce laws related to mammography that are at least as stringent as the federal law. 42 U.S.C. § 263b(m).

In Texas, DSHS enforces the Mammography Quality Standards

Act. Tex. Health & Safety Code § 401.423(b). To perform mammography in Texas, a person must apply for certification and use a certified mammography system. Tex. Health & Safety Code §§ 401.422(a), .426.

The mammography system must meet certain requirements, including that it be operated by a certified medical radiologic technologist and be used at a facility that has a quality control program. Tex. Health & Safety

Code § 401.424(a)(3), (4)(D). DSHS promulgated further requirements for providing mammography services in its rules. 25 Tex. Admin. Code § 289.

APPELLEE’S BRIEF Page 24 of 41

Though Dr. Guevara argues that an RSO is merely a technical role that concerns the use, handling, and storage of radioactive materials

(Appellant’s Br. at 25), as MAB’s RSO, Dr. Guevara had a duty to ensure

MAB’s regulatory compliance. He had the duty to “ensure that personnel are adequately trained and complying with” the regulatory requirements in 25 Texas Administrative Code Chapter 289. 25 Tex. Admin. Code §

289.226(n)(2) (emphasis added). Chapter 289 delineates radiation control requirements in facilities, including the certification of mammography systems and mammography accreditation. 25 Tex. Admin. Code §§

289.230, .234. Chapter 289 specifically requires that mammography facilities establish and maintain a quality assurance program, employ qualified personnel, and provide written communication to patients about their results. In addition to failing to ensure compliance with

Chapter 289, Dr. Guevara failed to ensure that a licensed physician supervised MAB’s techs, as required by statute. Tex. Occ. Code §

601.002(6)-(7). Dr. Guevara argues that substantial evidence does not

support TMB’s finding that he failed to practice in an acceptable manner, (Appellant’s Br. at 30-33), but the record shows otherwise, as detailed in the following subsections. Staff Ex. 42 at TMB1851; Tr. 34:09-34.16;

APPELLEE’S BRIEF Page 25 of 41

82:12-83.01; Staff Ex. 44 at TMB2031, 2034-35, 2055.

A. Dr. Guevara failed to ensure that MAB established and maintained a quality assurance and control program.

As MAB’s RSO, Dr. Guevara should have ensured that MAB’s imaging facility established and maintained a quality-assurance-and- control program. 25 Tex. Admin. Code § 289.230(u)-(w). Every mammography facility must “establish and maintain a written quality assurance program to ensure the safety, reliability, clarity, and accuracy

of mammography services performed at the mammography facility, including corrective actions to be taken if images are of poor quality.” 25

Tex. Admin. Code § 289.230(u). Chapter 289 provides detailed requirements for a quality-assurance-and-control program.

Responsibility for the quality assurance program must be assigned to qualified individuals, including a lead interpreting physician. 25 Tex.

Admin. Code § 289.230(u)(1)(A). The lead interpreting physician must ensure that the quality-assurance-and-control program substantially complies with the manufacturer’s recommendations for the image receptor. 5 25 Tex. Admin. Code § 289.230(v)(7). A corrective action plan

5 This applies as long as the system uses an image receptor modality other than screen film.

APPELLEE’S BRIEF Page 26 of 41 for failed quality assurance tests must also be enacted. Further, as part of the quality-assurance-and-control program, radiology facilities must undergo an annual survey by a medical physicist, evaluate new equipment, and establish protocols to keep the facility clean (in addition to other measures). 25 Tex. Admin. Code § 289.230(v)(6), (9)-(14). A quality-assurance-and-control program must also establish an annual mammography medical outcomes audit to follow-up on positive mammographic assessments. 25 Tex. Admin. Code § 289.230(w).

Substantial evidence in this case demonstrates that Dr. Guevara

did not ensure that Dr. Kapilivsky, MAB’s lead interpreting physician, instituted and maintained a quality-assurance-and-control program. Dr.

Kapilivsky was unaware that he needed to establish and maintain a quality assurance program. Tr. 82:17-83:01. No evidence exists to demonstrate that Dr. Guevara ever informed Dr. Kapilivsky that he would need to create and maintain a quality assurance program, even after he became aware that such a program was not in place. Dr.

Kapilivsky testified that Dr. Guevara never even discussed a quality assurance program with him. Tr. 34:09-34:16; 82:12-83:01. Dr.

Kapilivsky believed that his duties only entailed reviewing images taken

APPELLEE’S BRIEF Page 27 of 41 by MAB’s radiology techs and providing written reports. Tr. 32:11-32:13, 69:06-69:13, 82:17-83:01.

Due to Dr. Guevara’s failure as an RSO, MAB did not maintain a written quality assurance program or perform quality control tests as recommended by the manufacturer. Staff Ex. 44 at TMB2047-48, 2055.

Additionally, because no quality assurance program existed, Dr.

Kapilivsky did not review and document quality control test results. Staff

Ex. 44 at TMB2047-48, 2055. The failure to establish a quality assurance program means that Dr. Guevara’s patients unknowingly relied on unreliable imaging.

B. Dr. Guevara failed to ensure that MAB employed qualified personnel to perform mammography imaging.

As MAB’s RSO, Dr. Guevara had the duty to ensure that MAB employed certified medical radiologic technologists qualified to perform mammography. 25 Tex. Admin. Code § 289.230(r)(2). Substantial evidence demonstrates that Dr. Guevara did not ensure that MAB employed qualified personnel to perform mammography.

MAB hired Sergio Lugo to work as a mammogram tech from

November 2018 to January 2019. A.R. at TMB1215. Sergio Lugo’s

APPELLEE’S BRIEF Page 28 of 41 mammography license had been revoked in 2010, and that sanction

remained in place until 2018. Staff Ex. 44 at TMB2031, 2054-55. The license could not be reactivated without a test, which Sergio Lugo took on December 18, 2018, but at no time during Sergio Lugo’s tenure did he have a license or any other qualification to perform mammography. Id.

As MAB’s RSO and owner, Dr. Guevara could have independently verified Sergio Lugo’s qualifications, but he did not. Staff. Ex. 42 at

TMB1844-45, 57:20-58:06. Instead, he placed the blame on his office manager for hiring Sergio Lugo. Id. When the office manager discussed

Sergio Lugo’s lack of qualifications, Dr. Guevara ignored the information and ordered Sergio Lugo to continue to perform mammograms. Staff Ex.

44 at TMB2031.

When DSHS conducted its investigation of the mammography imaging, it found that all 27 sampled images taken by Sergio Lugo failed to meet the standards of the American College of Radiology. A.R. at

TMB1216. All 30 of the images sampled by DSHS6 were of such poor quality that the images did not reveal whether or not the patient had

6 DSHS sampled a total of 30 images. Twenty-seven were taken by Sergio Lugo, and three were taken by Nancy Soto.

APPELLEE’S BRIEF Page 29 of 41 breast cancer. A.R. at TMB1216. Sergio Lugo’s images largely fell below mammography standards because he incorrectly positioned the patient’s breast, so that the machine could not capture an image of the whole breast, meaning cancer could be missed. Staff Ex. 44 at TMB2039, 2056.

Even though MAB created substandard images, MAB relied on these images in many cases. A.R. at TMB 1216.

C. Dr. Guevara failed to ensure that MAB provided the results of the mammography reports to each of his patients.

As MAB’s RSO, Dr. Guevara had the duty to ensure that MAB created mammography reports and communicated results to patients and their health care providers. 25 Tex. Admin. Code § 289.230(t). A mammography facility is required to communicate the results of a mammography exam within 30 days of the exam. 25 Tex. Admin. Code §

289.230(t)(2). The written report of results must include a final assessment of findings and recommendations of further action to be taken by the referring physician. 25 Tex. Admin. Code § 289.230(t)(1).

Substantial evidence demonstrates that Dr. Guevara failed to ensure that MAB provided written communication to its patients about

their mammography exams within 30 days. During the DSHS inspection, APPELLEE’S BRIEF Page 30 of 41

MAB could not confirm if it had sent out letters to its patients regarding their mammography exams within the required 30 days. Staff Ex. 44 at

TMB2034-35, 2055. At first, the facility could not find any letters, and then when it found some letters, it couldn’t determine if the letters had ever been sent out. Staff Ex. 44 at TMB2034-35, 2055.

By failing to ensure that MAB provided written communication to mammography patients, Dr. Guevara’s patients would have likely believed that their results indicated the absence of disease. But MAB likely failed to send out communications to mammography patients due to disorganization rather than to affirm that the patient did not have cancer. See Id. Therefore, Dr. Guevara’s patients’ reliance upon MAB’s non-communication would be misplaced due to MAB’s disorganization.

Without timely discussion of mammogram results, more detailed diagnostics such as 3D ultrasounds may not be pursued, and cancers may grow unchecked, resulting in potentially catastrophic consequences for Dr. Guevara’s patients.

III. The trial court correctly affirmed TMB’s Final Order because it was not arbitrary or capricious when it reached a reasonable result.

Finally, Dr. Guevara argues that TMB’s Final Order imposes

APPELLEE’S BRIEF Page 31 of 41 unreasonable, arbitrary, and capricious disciplinary actions (Appellant’s

Br. at 33-35). TMB’s Final Order prevents Dr. Guevara from being

associated with any imaging service, including owning, operating, or acting as an RSO for any imaging service. A.R. at TMB1213-1226. TMB’s disciplinary measures are not arbitrary or capricious because they are tailored to prevent a high risk to public health. Dr. Guevara’s gross

disregard for complying with Chapter 289 (Supra, section II), in conjunction with previous discipline from TMB (A.R. at TMB1335-41, 1349-55, Staff Ex. 36) and denial of all responsibility in this case (A.R. at

TMB1218) indicates that Dr. Guevara poses a risk to patient health when being associated with imaging services.

Dr. Guevara referred patients to MAB’s radiology service when he

knew that he had not fulfilled his duties as an RSO to ensure that the interpreting physician instituted a quality assurance program. As the owner of MAB, he should have known that he employed unqualified radiology techs. Dr. Guevara argues that his failings as an RSO are not connected to his practice of medicine. Appellant’s Br. at 24-29. TMB disagrees. Dr. Guevara’s failings as an RSO are directly connected to his practice of medicine because he referred patients to the MAB’s imaging

APPELLEE’S BRIEF Page 32 of 41 facility—a facility Dr. Guevara controlled as owner and RSO. Dr.

Guevara was in the best position to know that his company’s radiology services provided substandard imaging to his patients. The TMB correctly determined that Dr. Guevara could not be trusted to partner with his patients to direct the scope of the patients’ future health interventions in the field of imaging because he put his economic interests before the health of his patients.

Accordingly, the TMB’s Final Order was reasonable in scope and was not arbitrary or capricious. An agency's decision is not arbitrary or capricious when an agency considers all factors the legislature directs it to consider; does not consider irrelevant factors; and reaches a reasonable result after weighing relevant factors. City of El Paso v. Pub. Util.

Comm’n, 883 S.W.2d 179 (Tex. 1994).

TMB followed the legislature’s directives to discipline Dr. Guevara.

The legislature has authorized TMB to regulate and discipline physicians. Tex. Occ. Code §§ 151.003, 153.001(4). The legislature has

also directed TMB to take action against physicians who engage in unprofessional conduct that is likely to deceive or defraud the public when a physician “commits an act that violates any state or federal law”

APPELLEE’S BRIEF Page 33 of 41 in connection with his practice of medicine. Tex. Occ. Code §

164.053(a)(1). The legislature has further directed TMB to institute a disciplinary matrix to outline factors for TMB to consider during its determination of disciplinary action. Tex. Occ. Code § 164.001(f).

TMB is required to take disciplinary action against a licensed physician who violates a state or federal law, including the Medical

Practice Act and DSHS radiation rules. Tex. Occ. Code § 164.001. Once

TMB determines that a physician has committed an act described in Sections 164.051—164.054 of the Texas Medical Practice Act, then TMB shall “suspend, limit, or restrict the person’s license or other

authorization to practice medicine, including: a) limiting the practice of the person to or excluding one or more specified activities of medicine; or b) stipulating periodic board review.” Tex. Occ. Code § 164.001(b)(3).

When TMB imposes a sanction as a result of a hearing before

SOAH, TMB must follow its schedule of sanctions. Tex. Occ. Code §

164.001(e). The disciplinary sanction guidelines promote consistent sanctions for similar violations, but the guidelines also leave discretion for TMB to choose the appropriate sanction. 22 Tex. Admin. Code §

190.14(1); App. Tab A. The guidelines propose both low and high

APPELLEE’S BRIEF Page 34 of 41 sanctions from which TMB may choose. 22 Tex. Admin. Code § 190.14(1);

App. Tab A. Ultimately, the choice of the sanction lies with the agency.

As long as the Court finds that TMB did not act arbitrarily or capriciously, then the Court must uphold the sanction, rather than reweighing the evidence to determine if the Court would choose the same sanction. See Stevens, 868 S.W.2d at 777-78.

Under TMB’s disciplinary matrix, when a physician falls below the standard of care, by violating a law, for more than one patient, and the physician had prior standard of care violations, then TMB may sanction the physician. 22 Tex. Admin. Code § 190.14(9); App. Tab A at 18. TMB’s

disciplinary matrix includes the potential low sanction of restricting the physician’s practice. 22 Tex. Admin. Code § 190.14(9); App. Tab A at 20.

TMB’s disciplinary matrix also includes the potential high sanction of suspending or revoking the physician’s license. 22 Tex. Admin. Code §

190.14(9); App. Tab A at 20.

TMB’s rules also allow the board to consider aggravating factors that warrant a more severe or restrictive disciplinary action. 22 Tex.

Admin. Code § 190.15. Aggravating factors may include 1) the increased potential for harm to the public; 2) previous discipline by TMB; and 3)

APPELLEE’S BRIEF Page 35 of 41 other relevant circumstances increasing the severity of the misconduct.

22 Tex. Admin. Code § 190.15(a). TMB found that Dr. Guevara committed three aggravating factors.

First, TMB found that Dr. Guevara’s imaging practice increased the potential for harm to the public. One hundred percent of the mammography images reviewed by DSHS fell below the American

College of Radiology’s standard. A.R. at TMB1216. Therefore, allowing

Dr. Guevara to continue to operate an imaging practice when he had notice of MAB’s mammography facility’s inadequacy but chose to do nothing, would put the public at risk. Secondly, the TMB noted that Dr.

Guevara has previously faced two separate disciplinary actions by TMB.

Dr. Guevara entered into an Agreed Order in 2010 regarding inadequate medical records. Staff Ex. 36 at TMB1335-41. TMB also adopted an

Agreed Order in 2012, which disciplined Dr. Guevara after he failed to document a plan to follow up on an abnormal X-ray and that patient later received a Stage IV Cancer diagnosis. Staff Ex. 36 at TMB1349-55.

Finally, TMB determined that Dr. Guevara continuously minimized his

responsibility for the poor performance of MAB’s radiology facility and did not accept responsibility for hiring unqualified personnel. A.R. at

APPELLEE’S BRIEF Page 36 of 41

TMB1218, 1220. TMB considered this to be a relevant ‘other’ factor that would increase the severity of Dr. Guevara’s misconduct.

TMB acted reasonably instead of arbitrarily and capriciously when it limited Dr. Guevara’s practice by restricting him from owning/operating or otherwise being associated with an imaging practice.

Dr. Guevara engaged in unprofessional conduct in connection to his practice of medicine that was likely to deceive and defraud the public. See

Supra, section I; Tex. Occ. Code §§ 164.051(a)(1), .052(a)(5), .053(a)(1), .053(a)(8), .053(a)(9); A.R. at TMB1220. Therefore, TMB determined that merely preventing Dr. Guevara from being associated with

mammography, performing mammography, and supervising or delegating mammography would not be enough to protect his patients and the public. A.R. at TMB1220.

Instead, TMB issued its Final Order, which prevents Dr. Guevara from being associated with any imaging service, including, performing imaging services and supervising or delegating imaging services. A.R. at

TMB1221. In weighing the evidence, the TMB found this broader ban was necessary to prevent risk to the public because Dr. Guevara fell below the standard of care for multiple patients by referring them to

APPELLEE’S BRIEF Page 37 of 41

MAB’s substandard mammography facility when he had the responsibility to ensure that it had a quality assurance program in place.

See 22 Tex. Admin. Code § 190.14(9); App. Tab A at 18-20; 25 Tex. Admin.

Code § 289.226(n)(2).

The TMB had the authority to revoke Dr. Guevara’s license entirely but instead chose to restrict his practice to non-imaging services. Because

TMB had the discretion to choose this sanction and only considered relevant factors in the determination of its sanction, TMB’s Final Order is neither arbitrary, nor capricious, nor an abuse of discretion.

CONCLUSION

Appellee TMB respectfully requests the Court affirm the trial court’s final judgment and the TMB’s Final Order in all respects. TMB further requests such other and further relief as the Court may deem just.

APPELLEE’S BRIEF Page 38 of 41

Respectfully submitted, KEN PAXTON Attorney General of Texas

BRENT WEBSTER First Assistant Attorney General

RALPH MOLINA Deputy First Assistant Attorney General

AUSTIN KINGHORN Deputy Attorney General for Civil Litigation

ERNEST C. GARCIA Chief, Administrative Law Division

/s/ Kathy Johnson KATHY JOHNSON Assistant Attorney General Texas State Bar No. 24126964 TED A. ROSS Assistant Attorney General Texas State Bar No. 24008890

Office of the Attorney General Administrative Law Division P.O. Box 12548, Capitol Station Austin, Texas 78711-2548 Telephone: (512) 475-4164 Facsimile: (512) 320-0167 [email protected] [email protected]

ATTORNEYS FOR APPELLEE TEXAS MEDICAL BOARD

APPELLEE’S BRIEF Page 39 of 41

CERTIFICATE OF COMPLIANCE

In compliance with Texas Rule of Appellate Procedure 9.4(i) and relying on the word count function in the word processing software used to produce this document, I certify that the number of words in this document is 5,449, excluding those portions exempted by Rule 9.4(i)(1).

/s/Kathy Johnson Kathy Johnson ASSISTANT ATTORNEY GENERAL

CERTIFICATE OF SERVICE

I hereby certify that on September 29, 2025, a true and correct copy of the above and foregoing document was sent to the following attorneys in charge via electronic service and/or electronic mail:

Hayley Ellison Davis & Santos, PLLC 719 S. Flores St. San Antonio, TX 78204 P: 210-853-5882 [email protected]

ATTORNEY FOR APPELLANT

/s/Kathy Johnson Kathy Johnson ASSISTANT ATTORNEY GENERAL

APPELLEE’S BRIEF Page 40 of 41

APPENDICES

Tab A - TMB Disciplinary Matrix

APPELLEE’S BRIEF Page 41 of 41

APPENDIX A

Figure: 22 TAC §190.14(9)

Violation Statutory/Rule Citation Low Sanction High Sanction Description Abusive or §164.052(a)(5) Remedial Plan: Agreed Order with Disruptive (unprofessional conduct Anger IME or Public Behavior likely to injure public); management Referral to PHP; Rule §190.8(2)(K), (P) and CME in medical communications ethics, anger CME, JP exam, management, medical ethics communications with colleagues, JP exam. For multiple orders or egregious actions- -interfering with patient care: public reprimand, suspension with terms and conditions Aiding in §164.052(a)(17) (directly Remedial Plan: Agreed Order: unlicensed or indirectly aids or abets Directed CME in Public practice unlicensed practice) supervision or reprimand, all delegation if sanctions in low applicable; 8 hours category, plus CME in medical $2,000 admin ethics, 8 hours penalty CME in risk management; must pass JP within 1 year Bad faith §1467.101 and 1467.102 Good cause Agreed Order: mediation by a of the Texas Insurance shown: Public licensee in Code (bad faith in Remedial Plan: 8 reprimand; $5,000 relation out-of-network hours of medical admin penalty, to an out-of- claim dispute ethics; otherwise, "except for good network health resolution)--"except admin penalty is cause shown" per benefit claim for good cause shown, the statutorily required §1467.102; plus regulatory agency shall all

impose sanctions in low an administrative penalty" category Boundary §164.052(a)(5) RP is statutorily Cases involving Violation: (unprofessional conduct prohibited physical contact: Engaging in likely to injure public); Verbal remarks, or Agreed Order: sexual contact Rule §190.8(2)(E)-(F) inappropriate Low with a patient or behavior, but not sanctions plus engaging in involving touching: IME, sexually Agreed Order: Replace inappropriate Public reprimand; chaperone behavior or Vanderbilt or with may not treat comments PACE patient of the directed boundaries course; affected gender; towards a patient JP exam; CME in or ethics; chaperone suspension or revocation Boundary §164.052(a)(5)(unprofession RP is statutorily More than one Violation: al prohibited incident (more Becoming conduct likely to injure Single incident: than financially public); Agreed Order: one patient, or or personally Rule §190.8(2)(G) CME occasion): Agreed involved with a in ethics, JP exam; Order: Low patient in an if Sanctions plus: inappropriate financial Public reprimand; manner involvement, Vanderbilt or restitution if PACE appropriate; and/or boundaries admin penalty course; JP exam; CME in ethics; administrative penalty; or suspension or revocation Breach of §164.052(a)(5) Remedial Plan: 8 Agreed Order: Confidentiality (unprofessional conduct hours risk Public likely to injure public); management CME reprimand, CME in Rule §190.8(2)(N) to risk management include HIPAA, and in HIPAA $500 requirements; administration fee $3,000 per occurrence; JP exam Cease and desist §164.002 (Board's general order--issuance authority to dispose of "any

of: complaint or matter" unless See "Unlicensed precluded by another statute) practice of §165.052 (power to issue medicine" cease and desist orders against unlicensed persons) Cease and desist §165.052(b) (violation of Administrative Referral to order (existing), (c) and (d) is grounds for penalty Attorney violation of imposing admin penalty) $2,000 - $5,000 General for civil per penalty and costs offense or criminal prosecution. §165.101 (civil)and §165.152 (criminal) Change in §164.051(a)(3) Rule Remedial Plan: 4 Agreed Order: 8 practice §166.1(d) hours of ethics/risk hours of ethics/risk or mailing (notify Board within 30 days management and management; address, of $500 $2,000 admin failure to notify the change of mailing or practice administration penalty; JP exam board of address or professional name fee on file) CME - Failure to §164.051(a)(3) (forbids Remedial Plan: All Agreed Order: 8 obtain or breaking or attempting to missing hours of hours of CME in document CME break a Board rule); Rule CME and 4 hours ethics/risk §166.2 (48 credits each of management plus 24 months + other ethics/risk complete all requirements management and missing and accreditation of CME $500 hours; $1,000 req'ts) administration admin fee penalty; JP exam Crime: Abortion - §164.052(a)(16) (prohibits Agreed Order: Agreed Order: performing a performing, procuring, aiding, Public Suspension, criminal abortion. or Reprimand; must probated with Health and Safety abetting in procuring a pass JP within 1 terms, Code §170.002 criminal year; or revocation and Chapter 171 abortion); $5,000 admin (§170.002 §164.055 (requires penalty prohibits "appropriate third-trimester disciplinary action" against a abortions, with physician who violates Health exceptions; and Safety Code §170.002 or

Chapter 171 Chapter 171) requires physicians to make available certain materials to abortion patients and restricts how informed consent is obtained; the criminal offense (§171.018) is an unspecified class of misdemeanor punishable only by a $10,000 fine) Crime: Arrest for §164.0595 (Temporary Agreed Order: Agreed Order: offense under suspension or restriction Restriction of Suspension of Penal of license for certain arrests) license, license, no Code §§21.02; chaperone; may probation 21.11; not 22.011(a)(2); treat pediatric 22.021(a)(1)(B); patients (assaultive offenses against children) Crime: Deferred §164.057(c) (mandates Revocation is adjudication revocation upon proof of statutorily required community deferred adjudication supervision for community supervision) offense under Penal Code §§21.11; 22.011(a)(2); 22.021(a)(1)(B); (assaultive offenses against children) Crime: Felony §204.303(a)(2) of the Initial conviction: Revocation is conviction Physician Assistant Act; Statutorily required statutorily required §205.351(a)(7) of the §190.8(6)(A)(iv) on final conviction Acupuncture Act; and - §164.057(a)(1)(A) of the §164.057(a)(1)(A); §164.057(b) Medical Practice Act suspension to

(requires occur suspension on initial by operation of law conviction pursuant to for a felony) §187.72 Crime: Felony §204.303(a)(2) & (3) of the Agreed Order: Suspension or deferred Physician Assistant Act; Appropriate Revocation; adjudication; Board sanction §164.001(a); Misdemeanor Rule 185.17(7)& (11); such as referral to Revocation is involving moral §205.351(a)(7) of the PHP, anger statutorily required turpitude deferred Acupuncture Act; management, IME, on final conviction adjudication §164.051(a)(2)(A) of the restrictions on of Medical Practice Act practice, CME in a felony- (authorizes appropriate area §164.057(b) sanctions for initial convictions and deferred adjudications for felonies and misdemeanors involving moral turpitude) Crime: §204.303(a)(2) of the If the offense is not If the offense is Misdemeanor Physician Assistant Act; related to the related to the conviction of §205.351(a)(7) of the duties duties crime Acupuncture Act; and responsibilities and involving moral §164.051(a)(2)(B) of the of responsibilities turpitude Medical Practice Act the licensed of the licensed (authorizes suspension on occupation, the occupation, the initial conviction for standard sanction standard sanction misdemeanor shall require: shall be revocation of moral turpitude, and (-a-) Suspension of of the license. revocation license, which may upon final conviction) be probated; (-b-) compliance with all restrictions, conditions and terms imposed by any order of probation or deferred adjudication; (-c-) public reprimand; and (-d-) administrative penalty of $2,000

per violation. Crime: Texas Occupations Code Suspension Revocation Misdemeanor §53.021; conviction not Rule §190.8(6)(B)(iv) stating involving moral Chapter 53 of applies to turpitude that is misdemeanor convictions not connected with involving moral turpitude but the connected with the physician's physicians practice of practice of medicine and medicine setting out factors showing connection to practice of medicine Crime: §164.057(a)(1)(B), (C), Suspension is Revocation is Misdemeanor (D), and (E) (when statutorily required statutorily required initial conviction misdemeanor conviction per on final conviction under Penal Code requires suspension) §164.057(a)(1)(B) - Chapter 22 §164.057(b) (assaultive offenses - see also: arrest or deferred adjudication for assaultive offenses against children) of crime punishable by more than a fine; OR Penal Code §25.07 (violation of court order re: family violence); OR §25.071 (violation of court order re: crime of bias or prejudice); OR one requiring registration as a sex offender under

Code of Criminal Procedures Chapter 62 Death certificate, §164.053(a)(1) (authorizes Remedial Plan: 4 Agreed Order: failure to sign sanctions via §164.052(a)(5) hours of ethics/risk CME – 8 hours of electronically for management risk management, breaking any law that "is and $500 4 connected with the administration fee – 8 hours medical physician's ethics; $2,000 practice of medicine"); Health admin and Safety Code Chapter 193 penalty; JP exam (requires electronic filing of death certificates) Delegation of §164.053(a)(9) (describes Remedial Plan: 12 Agreed Order: professional the violation as hours CME in Low medical unprofessional supervision and sanctions plus no responsibility or conduct, allows sanctions) delegation, 8 hours delegation or acts to person if in supervision the physician risk management, authority; knows 8 administrative or has reason to hours in medical penalty of $2,000 know that the ethics; JP exam per person violation is not qualified by training, experience, or licensure to perform the responsibility or acts Discipline by §164.051(a)(7) (describes Agreed Order: See Agreed Order: peers, may be offense: includes being the applicable Public either an subjected sanction for the reprimand; comply administrative to disciplinary action taken by violation of the with all violation or SOC peers in a local, regional, Texas restrictions, state, Medical Practice conditions and or national professional Act terms medical that most closely imposed by the ass'n or being disciplined by a relates to the basis disciplinary action licensed hospital or medical of by staff the disciplinary peers to the extent of a hospital, including action possible; and removal, by peers. In administrative suspension, limitation of addition, penalty of $3,000 privileges, or other action IF the licensee shall per

the comply with all violation, plus board finds the action was restrictions, directed CME and, based conditions and if on unprofessional conduct terms SOC case, a chart or professional incompetence imposed by the monitor. If not that was likely to harm the disciplinary action SOC: public by IME; anger and "was appropriate and peers to the extent management; reasonably supported by possible. CME evidence submitted to the in communications board." Expert panel report provides such evidence) Disciplined by §164.051(a)(9) (describes If no standard of If out-of-state another state or the violation, requires that care order military may be acts for which discipline concerns, is revocation, either an imposed be the same or Remedial revocation is administrative similar to acts in §164.052 or Plan with statutorily violation or a acts appropriate required. patient care that are the same or similar to CME and $500 violation acts described in 164.051(a), administration fee; for OR reciprocal example rule violations, SOC Agreed violations, and all forms of Order as impairment) Issue is only appropriate. whether there was an order--no relitigation of prior facts, e.g., no new expert panel required Drug logs - Failure §164.053(a)(2) (describes Remedial Plan: 8 Agreed Order: to maintain (see offense and refers to Chapter hours of ethics/risk Public also, violation of 481 Health and Safety Code management reprimand; 8 state or federal and and $500 hours law connected 21 USC §801 et seq.) administration fee of ethics/risk with practice) management; $2,000 admin penalty; JP exam Employing a §164.052(a)(14) (describes Agreed Order: Agreed Order: revoked/cancelled offense: "directly or indirectly Public Public / employs . . .); reprimand; $3,000 reprimand; $5,000 or suspended §164.052(a)(15) (forbids admin penalty; admin penalty; JP physician (see associating in the practice take exam; no also of medicine with such a and pass JP exam delegation aiding and person) authority

abetting the unlicensed practice) Failing to §164.053(a)(8); Remedial Plan: 12 Agreed Order: adequately §164.053(a)(9) - These hours CME in Low supervise sections describe the supervision and category subordinates and respective violations and delegation; sanctions improper define them as consider plus: monitoring of delegation unprofessional ordering Rsp to practice; no conduct furnish ED copies delegation or of supervision delegation orders authority; of administrative develop and penalty of $2,000 furnish per delegation orders violation; JP exam to ED; $500 admin fee Fails to keep §164.051(a)(3) Remedial Plan: Agreed Order: 8 or proper medical (authorizes sanctioning CME more hours of records rule violations); in appropriate medical record- §164.051(a)(6) area; keeping, require (authorizes sanctioning $500 in- failure to practice acceptably administration person attendance consistent with public fee if welfare); practical; chart Rule §165.1 describes monitor 8 – 12 contents of an adequate cycles; $2,000 medical record admin penalty; JP exam; PACE course in medical record- keeping if prior order for inadequate record-keeping Failure to §164.052(a)(5) (prohibits Single incident: Multiple instances: Communicate conduct that is "likely to Remedial Plan--8 Agreed with deceive hours risk Order: Public patient or other or defraud the public" and management CME reprimand, risk providers unprofessional conduct as to management and defined by §164.053) include patient communications communications, CME, fine, $500 counseling, IME administration

fee Failure to display Rule §178.3(a)(1) Remedial Plan: 4 Agreed Order: 8 a (requires display of sign) hours of ethics/risk hours of ethics/risk "Notice management management, Concerning and $500 $1,000 admin Complaints" sign administration fee penalty; JP exam Failure to report §164.052(a)(5) (prohibits Single incident: Multiple or dangerous conduct that is "likely to Agreed Order: egregious: behavior to deceive or defraud the Admin Agreed Order: governmental public" and unprofessional penalty; CME in Low body conduct as defined by medical ethics; JP category §164.053) exam sanctions plus public reprimand and $5,000 admin penalty Failure to Pay/CS Gov't Code; Family Code Suspension until Suspension until Chapter 232 (authorizes such time as the such time as the suspending licenses of any licensee is no licensee is no kind longer longer granted by the state to in default is in default - persons required statutorily who do not pay support – statutorily required payments) required Failure to Pay §56.003 of the Texas Agreed Order: Suspension until Student Loan Occupations Code public such time as the reprimand; within a licensee is no certain time frame, longer provide proof of in default entering into an agreement with the loan servicing agent and/or default has been cured. Auto- suspend if violate order Failure to report §164.052(a)(5)(prohibits Remedial Plan; Agreed Order: suspected abuse conduct CME- Low of that is “likely to deceive or 8 hrs risk sanctions plus a patient by a third defraud the public” and management; JP public party, when the unprofessional conduct as Exam reprimand; report of that defined by §164.053); administrative abuse Rule §190.8(2)(O) penalty

is required by law $3,000 per violation Fees, failure to §101.203 (prohibits Remedial Plan: 8 Agreed Order: 8 - provide overbilling via hours of ethics/risk 16 explanation of ref to Health and Safety Code management/billin hours of CME in §311.025); §101.351 g ethics, risk (establishes practices and $500 management, requirement and excludes administration fee billing application of §101.351 to practices, and physicians who post a billing CPT practice sign in their waiting coding, $2,000 room) admin penalty Fraud on a §164.052(a)(2); Misrepresentations If diploma/in an §164.052(a)(3) (describes that do not make misrepresentation exam offense as presenting an licensee/applicant makes the illegally or fraudulently ineligible: licensee obtained credential and Remedial ineligible, then cheating on exams) Plan - 8 hours of revocation. ethics/risk management and $500 administration fee Fraudulent, §101.203 (prohibits Agreed order: Agreed Order: improper overbilling via ref to Including, Public billing practices - Health and Safety Code but not limited to: reprimand, requires that §311.0025); monitoring of monitoring of Respondent §164.053(a)(7) (prohibits billing practice, including knows violation of Health and practices; directed billing practices; the service was Safety Code §311.0025) CME; restitution; directed CME; not and restitution; and provided or knows administrative administrative was improper, penalty penalty of $3,000 unreasonable, or of $1,000, but not per medically or to violation clinically exceed the amount unnecessary. of Should not improper billing sanction for an unknowing and isolated episode. Health care §160.052(b) (requires Remedial Plan: 4 Agreed Order: 8 liability reporting health care liability hours of ethics/risk hours of ethics/risk claim, failure to claims to Board) Rule §176.2 management management;

report and and $500 $2,000 admin §176.9 (prescribes form for administration fee penalty; JP exam such reporting) Impairment (no §164.051(a)(4) (authorizes Refer to Voluntary history and no sanctions for practicing by PHP--Public surrender aggravating those referral via agreed or temporary factors such as unable because of illness, order required if suspension SOC, boundary drunkenness, excessive case involves violation, or use of substances, or a discharge from felony) mental or PHP, physical condition); otherwise private §164.052(a)(4) (forbids use referral is OK if of appropriate alcohol or drugs in an intemperate manner that could endanger a patient's life) Impairment (with §164.051(a)(4) (authorizes Agreed Order: IME Agreed Order: history or SOC sanctions for practicing by with report to ED or Suspension of violation or those unable because of to panel at re- license until such boundary violation illness, convened ISC, time as the or felony) drunkenness, excessive use restrict practice or licensee of voluntary can demonstrate substances, or a mental or suspension that the licensee is physical condition); pending report; if safe and §164.052(a)(4) (forbids use impairment is competent of found to practice alcohol or drugs in an at ISC, suspension medicine intemperate manner that of OR Suspension could license until such probated for 10 endanger a patient's life) time as the years with terms licensee and can demonstrate conditions that the licensee is including safe and but not necessarily competent limited to: drug to practice testing; medicine, restrictions with conditions to on practice; AA or be NA attendance determined by a evidenced by logs; subsequent panel IME for psychiatric/ psychological

evaluation and treatment; proficiency testing OR revocation. Intimidation of §164.052(a)(5) (prohibits Single Incident: Multiple/Egregious Complainant unprofessional conduct as Public reprimand : defined by §164.053 or and Suspension that is "likely to deceive or fine and/or defraud the public") revocation; significant admin penalty; CME in ethics; JP exam Medical Records: §159.006 of the Act Remedial Plan: 4 Agreed Order: 8 failure to release/ (information furnished by hours of ethics/risk hours of ethics/risk Overcharging for licensee); §164.051(a)(3) management and management, (prohibits rule violations); $500 $2,000 admin Rule administration penalty; JP exam. §165.2 (requires release to fee Also, §159.006 proper person as described (Board may therein unless release would appoint harm the patient and temp or prescribes permanent allowable charges custodian of patient records held by a physician) Misleading §164.051(a)(3); Remedial Plan: 8 Agreed Order: 16 advertising §164.052(6) hours of ethics/risk hours of ethics/risk (prohibits false advertising); management, management in Rule correct the person, correct the §164.3, §164. advertisement advertisement, and $500 $5,000 admin administration fee penalty, JP exam Operating an §158.001(b) (requires Agreed Order: Agreed Order: JP unlicensed physicians to comply with Must exam; cease pharmacy Occupations Code Chapter pass JP within 1 operating 558 year, pharmacy; to operate a retail pharmacy) $2,000 penalty, CME – ethics and CME risk management – medical ethics Overbilling: See fraudulent, improper billing

Peer review action: See Discipline by peers Physician-patient Rule §190.8(1)(J) Single incident: Multiple instances: relationship, (requires reasonable Remedial Public reprimand, Improper notice to patient of Plan: 8 hours CME risk management, termination of termination) - fine, CME - in 4 risk management physician-patient and 4 ethics, $500 communications administration fee Pill mills, Revocation unregistered pain clinics, overprescribing – See Delegation, Supervision, Prescribing Prescribing §164.051(a)(6); Rule Agreed Order Agreed Order controlled §190.8(1)(L), (M) CME 8 hours Low sanctions substances to medical plus oneself, family recordkeeping, or public reprimand; members, or risk management; restrictions on others in which 8 prescribing to self, there is a close hours appropriate family, and others personal prescribing of in relationship controlled which there is a absent immediate substances; JP close personal need, without Exam relationship, taking an restrictions on adequate history, If only one practice including performing a prescription and no restrictions on proper physical evidence of prescribing and examination, pattern, administering or creating and the ISC Panel may controlled maintaining consider a substances and adequate remedial dangerous drugs, records plan. administrative penalty of $3,000 per violation Prescribing §164.051(a)(6); Rule Remedial Plan: Agreed Order: dangerous drugs §190.8(1)(L), (M) CME - 8 hours Low to oneself, family medical sanctions plus members, or recordkeeping or restrictions on

others in which risk prescribing to self, there is a close management; JP family, and others personal Exam in relationship which there is a without taking an close personal adequate history, relationship and performing a administrative proper physical penalty of $2,000 examination, per or creating and violation maintaining adequate records Prescribing, writes §164.053(a)(3),(a)(4) Agreed Order: Agreed Order false or fictitious (defines the violations under CME - Low sanctions prescriptions OR unprofessional conduct) 8 hours drug- plus: prescribes or seeking behavior, restrictions on dispenses drugs 8 practice including to hours risk restrictions on a person who is management; prescribing and known to be an chart administering abuser of narcotic monitor at least 8 controlled drugs, controlled cycles; if substances and substances, or Respondent dangerous drugs; dangerous drugs does not use one, proficiency testing; OR order to develop a directed CME; and writes pain management increase prescriptions contract with administrative for or dispenses to specific penalty to $5,000 a person who the provisions for per physician should termination of violation. have known was physician-patient an abuser of relationship on a If evidence of false narcotic drugs, maximum of 3 or fictitious controlled violations by the prescriptions, substances, or patient including a surrender DEA dangerous drugs positive test for a registration controlled certificate substance for all controlled not prescribed by substance Respondent, drug schedules. screens required by contract; JP Exam; admin penalty of $3,000 per violation

Prescribing, §164.053(a)(5),(a)(6) Remedial Plan Agreed Order: nontherapeutic--o (prohibits prescribing or CME in Proficiency r administering any drug or appropriate testing, treatment that is area; $500 CME in dispensing, or nontherapeutic administration fee appropriate administering of per se or because of the per year. area; chart drugs way it is administered or monitor nontherapeutically prescribed) for 8 cycles; , administrative one patient, no penalty of $3,000 prior board per violation disciplinary history related to standard of care or care- related violations

OR prescribing, administering, or dispensing in a manner inconsistent with public health and welfare, one patient, no prior board disciplinary history related to standard of care or care- related violations

Prescribing, §164.053(a)(5),(a)(6) Agreed Order: Agreed Order: nontherapeutic--o (prohibits prescribing or Proficiency testing; Low r administering any drug or CME in sanctions plus dispensing, or treatment that is appropriate restrictions on administering of nontherapeutic area; chart monitor practice, including drugs per se or because of the 12 cycles; prescribing and nontherapeutically way it is administered or administrative administering More than one prescribed) penalty $3,000 per controlled patient or prior violation substances and history of dangerous drugs;

disciplinary action and administrative for standard of penalty of $5,000 care or care- per related violations violation. If there are OR aggravating prescribing, factors, administering, or revocation should dispensing in a be manner considered. inconsistent with public health and welfare, more than one patient or prior history of disciplinary action for standard of care or care- related violations Referring a patient §164.052(a)(5) Remedial Plan: Agreed Order: to a facility, (prohibits conduct that is CME 8 hrs ethics, Low sanctions laboratory, or "likely to 8 plus pharmacy without deceive or defraud the public" hrs risk public reprimand; disclosing the and unprofessional conduct management; JP existence of the as within Exam; licensee’s defined by §164.053); 30 days of order’s administrative ownership Rule §190.8(2)(H) entry, provide penalty interest in the proof $3,000 per entity of implement of violation to the patient form used to disclose ownership to interest Refusal to §160.009 of the Act If records If records never respond and Rule §179.4 (relating to eventually received to board Request for Information and received, and intentionally subpoena Records from Physicians); Remedial withheld, or request for §164.052(a)(5), as further Plan of 8 hours of Agreed Order: information or defined by Board Rule ethics/risk public action 190.8(2)(B) (prohibits management and reprimand; JP Unprofessional conduct as $500 exam; defined by §164.053 or that is administration admin penalty; "likely to deceive or defraud fee CME the in medical ethics

public") Reporting false or §164.052(a)(1) Misrepresentations If misleading (forbids submission that do not make misrepresentation information on an of false or misleading licensee/applicant makes the initial application statements of documents in ineligible: licensee for licensure or for an Remedial ineligible, then licensure renewal application for a license) Plan - 8 hours of revocation. ethics/risk management and $500 administration fee Reporting false or §164.052(a)(5), as further Remedial Plan - 8 Agreed Order: misleading defined hours of ethics/risk 8 hours of Board (non- by Rule §190.8(2)(C) management and ethics/risk licensing matter) $500 management administration JP Exam fee administrative penalty of $3,000 Self-Prescribing: See "Prescribing to self." Solicitation of §165.155 (provides a Agreed Order (if no Egregious: Agreed patients/Drummin Class A misdemeanor conviction): 8 Order: Public g penalty) hours reprimand, chart of ethics/risk sign management off, $5,000 fine, JP and $500 exam, CME in administration fee medical ethics OR referral to county attorney for prosecution as Class A misdemeanor under §165.155(e) Standard of §164.051(a)(6) (fails to Remedial Plan*: Agreed Order: Care - one practice CME in Proficiency patient, no prior medicine in an acceptable, appropriate testing; SOC or care- professional manner area; $500 directed CME; related violations consistent administration chart with public health and fee per year. monitor for 8 welfare) *No RP if case cycles; concerns a administrative patient death penalty

of $3,000 per violation Standard of §164.051(a)(6) (fails to Agreed Order: Agreed Order: care - one practice Chart Limiting the patient, one medicine in an acceptable, monitor for 8 practice prior SOC or professional manner cycles; of the person or care-related consistent directed CME, excluding one or violation with public health and administrative more specified welfare) penalty activities of of $3,000 per medicine; violation proficiency testing; directed CME; monitoring of the practice (either chart monitor for 12 cycles or supervising physician for a number of cases or specified period of time); public reprimand; and administrative penalty of $5,000 per violation. Standard of care - §164.051(a)(6) (fails to Agreed Order: Agreed Order: K- one patient, more practice Limiting the STAR or PACE or than one prior medicine in an acceptable, practice equivalent SOC or care- professional manner of the person or proficiency related violation consistent excluding one or testing; directed with public health and more specified CME; chart welfare); activities of monitoring (either §164.051(a)(8) (recurring medicine; chart monitor for meritorious healthcare proficiency testing; 16 liability directed CME; cycles or claims that evidence monitoring of the supervising professional practice (either physician for a incompetence likely to injure chart number of cases the monitor for 12 or public); Rule §190.8(5) cycles specified period of (defines or supervising time), restricting

"recurring" as 3 or more physician for a the claims number of cases or practice; awarded or settled for specified period of withdrawal $50,000 in time); of prescribing a 5-year period) administrative privileges or penalty of $ 3,000 delegating per privileges; violation public reprimand; administrative penalty of $5,000 per violation Standard of §164.051(a)(6) (fails to Agreed Order: Agreed Order: care - more practice Chart Monitor for 8 Proficiency than one patient, medicine in an acceptable, cycles; CME in testing; no prior SOC or professional manner appropriate area; directed CME; care- consistent administrative chart related violation with public health and penalty monitor 12 cycles; welfare); of $3,000 per public reprimand; §164.051(a)(8) (recurring violation and administrative meritorious healthcare penalty of $5,000 liability per claims that evidence violation professional incompetence); Rule §190.8(5) (defines "recurring" as 3 or more claims awarded or settled for $50,000 in a 5-year period) Standard of care - §164.051(a)(6) (fails to Agreed Order: Suspension or more than one practice Proficiency testing; revocation patient, prior SOC medicine in an acceptable, directed CME; or care-related professional manner monitoring for 12 violations consistent cycles; requiring with public health and oversight or welfare); restricting of the §164.051(a)(8) (recurring practice; public meritorious healthcare reprimand; and liability administrative claims that evidence penalty professional of $5,000 per incompetence); Rule violation. §190.8(5) (defines "recurring" as 3 or

more claims awarded or settled for $50,000 in a 5-year period) Supervision of midlevels, failure to perform: See "Failing to adequately supervise subordinates and improper delegation." Unlicensed §165.052(a)(see Cease and Desist Cease and Desist practice of definition of "practice of Order and referral Order; referral to medicine medicine" at of Attorney General's §151.002(a)(13)) Order to District office for injunction Attorney or or civil penalties Attorney General Unsound Mind - §164.051(a)(5) (enables Suspension of Temporary adjudicated (See Board to take action if a license until such suspension also licensee or applicant "is time as the prior to seeking "Impairment') found by a court to be of licensee revocation; show unsound mind") can demonstrate cause hearing that under the licensee is safe §164.056 and competent to practice medicine; IME and return to ISC panel with results Violation of Board §164.052(a)(5) (enables Administrative in Agreed Order: Order sanctioning of unprofessional nature- Agreed Low or Order: sanctions plus: dishonorable conduct as Administrative public reprimand; defined by §164.053 or Penalty of $1,000; admin penalty of conduct Substantive in $3,000 - $5,000 that injures the public) nature-extension of order and increase the terms of the original order Violation of state §164.053(a)(1) (authorizes If criminal law, see Agreed Order: or federal law sanctions via §164.052(a)(5) above under public

connected with for "Crime." reprimand; physician's breaking any law that "is If civil law, Agreed restriction practice connected with the Order: must pass of license; physician's JP surrender practice of medicine") exam and 8 hours of controlled of substance risk privileges; management/ethic plus low sanctions s

Automated Certificate of eService This automated certificate of service was created by the efiling system. The filer served this document via email generated by the efiling system on the date and to the persons listed below. The rules governing certificates of service have not changed. Filers must still provide a certificate of service that complies with all applicable rules.

Jeff Lutz on behalf of Kathy Johnson Bar No. 24126964 [email protected] Envelope ID: 106191658 Filing Code Description: Brief Not Requesting Oral Argument Filing Description: 2025 0929 TMB Appellee Brief Status as of 9/29/2025 11:52 AM CST

Case Contacts

Name BarNumber Email TimestampSubmitted Status

Jason M.Davis [email protected] 9/29/2025 11:34:23 AM SENT

Ted Ross 24008890 [email protected] 9/29/2025 11:34:23 AM SENT

Jeff Lutz [email protected] 9/29/2025 11:34:23 AM SENT

Hayley Ellison [email protected] 9/29/2025 11:34:23 AM SENT

Katherine Johnson 24126964 [email protected] 9/29/2025 11:34:23 AM SENT