08-004198N Hilda Rios And Jaime Rios, On Behalf Of And As Parents And Natural Guardians Of Maritza Rios, A Minor vs. Florida Birth-Related Neurological Injury Compensation Association Status: Closed DOAH Final Order on Friday, July 10, 2009.

Summary: Infant was not permanently and substantially mentally impaired. The Claim is denied.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

HILDA RIOS AND JAIME RIOS, ON )

BEHALF OF AND AS PARENTS AND )

NATURAL GUARDIANS OF MARITZA )

RIOS, A MINOR, )

)

Petitioners, )

)

vs. ) Case No. 08-4198N

)

FLORIDA BIRTH-RELATED NEUROLOGICAL INJURY )

COMPENSATION ASSOCIATION, )

)

)

Respondent, )

)

and )

)

WINTER HAVEN HOSPITAL, INC., )

d/b/a REGENCY MEDICAL CENTER; )

VINCENT W. GATTO, M.D.; )

STEFANIE L. YOUNG, ARNP; and )

BOND & STEELE CLINIC, PA, )

)

Intervenors. )

)

FINAL ORDER

Pursuant to notice, the Division of Administrative

Hearings, by Administrative Law Judge William J. Kendrick, held

a hearing in the above-styled case on May 18, 2009, by video

teleconference, with sites in Tallahassee and Lakeland, Florida.

APPEARANCES

For Petitioners: Armando T. Lauritano, Esquire

Morgan & Morgan, P.A.

One Tampa City Center

201 North Franklin Street, 7th Floor

Tampa, Florida 33602

For Respondent: David W. Black, Esquire

Frank, Weinberg & Black, P.L.

7805 Southwest Sixth Court

Plantation, Florida 33324

For Intervenor Winter Haven Hospital, Inc., d/b/a Regency

Medical Center:

John W. Bocchino, Esquire

Bobo, Ciotoli, Bocchino

Newman & Carsini, P.A.

Landmark Center One, Suite 510

315 East Robinson Street

Orlando, Florida 32801-1983

For Intervenors Vincent W. Gatto, M.D., Stefanie L. Young,

ARNP, and Bond & Steele, P.A.:

Andrew M. Brown, Esquire

MacFarlane, Ferguson & McMullen

Post Office Box 1531

Tampa, Florida 33601-1531

STATEMENT OF THE ISSUE

At issue is whether Maritza Rios, a minor, qualifies for

coverage under the Florida Birth-Related Neurological Injury

Compensation Plan (Plan).

PRELIMINARY STATEMENT

On August 25, 2008, Hilda Rios and Jaime Rios, on behalf of

and as parents and natural guardians of Maritza Rios (Maritza),

a minor, filed a petition (claim) with the Division of

Administrative Hearings (DOAH) for benefits under the Plan.

DOAH served the Florida Birth-Related Neurological Injury

Compensation Association (NICA) with a copy of the petition on

August 26, 2008, and on December 5, 2008, following an extension

of time within which to do so, NICA responded to the petition

and gave notice that it was of the view that Maritza did not

suffer a "birth-related neurological injury," as defined by

Section 766.302(2), Florida Statutes, because she was not

substantially mentally impaired, and requested that a hearing be

scheduled to resolve the issue of compensability. In the

interim, Winter Haven Hospital Inc., d/b/a Regency Medical

Center, was accorded leave to intervene, and on December 19,

2008, Vincent W. Gatto, M.D., Stefanie L. Young, ARNP, and Bond

& Steele Clinic, P.A., were accorded leave to intervene.

At hearing, Joint Exhibits 1-11 were received into

evidence. 1 No witnesses were called, and no further exhibits

were offered.

The transcript of the hearing was filed June 9, 2009, and

the parties were accorded 10 days from that date to file

proposed orders. Respondent and Intervenors elected to file

such proposals and they have been duly-considered.

FINDINGS OF FACT

Stipulated facts 2

1. Petitioners, Hilda Rios and Jaime Rios, are the parents

and natural guardians of Maritza Rios, a minor. Maritza was

born a live infant on October 10, 2005, at Winter Haven

Hospital, Inc., d/b/a Regency Medical Center, a licensed Florida

hospital located in Winter Haven, Florida, and her birth weight

exceeded 2,500 grams.

2. Obstetrical services were delivered at Maritza's birth

by Vincent W. Gatto, M.D., who, at all times material hereto,

was a "participating physician" in the Florida Birth-Related

Neurological Injury Compensation Plan, as defined by Section

766.302(7), Florida Statutes.

3. "Notice pursuant to § 766.316, Fla. Stat., was properly

given or excused, and is not an issue in this case."

4. Maritza suffered an injury to the brain, caused by

oxygen deprivation occurring in the course of labor, delivery,

or resuscitation in the immediate postdelivery period in the

hospital, which rendered her permanently and substantially

physically impaired. The only remaining issue is whether such

injury also rendered Maritza permanently and substantially

mentally impaired.

Findings related to Maritza's injury and her impairment

5. At NICA's request, Donald Willis, M.D., an

obstetrician/gynecologist, reviewed the medical records related

to Maritza's birth and newborn course, and concluded that

Maritza suffered an injury to the brain caused by oxygen

deprivation occurring in the course of labor, delivery, and the

immediately postdelivery period. Dr. Willis summarized the

basis for his conclusion, as follows:

I have reviewed the medical records for the

above individual. The mother, Hilda Rios,

was a 29 year old G4 P2103 with her first

baby born by Cesarean section and then two

vaginal births. Prenatal care was

uncomplicated. She presented at 38 weeks

with spontaneous rupture of the membranes.

Vaginal birth after Cesarean section was

planned.

The fetal heart rate pattern had a normal

baseline heart rate and was reactive on

admission [to Winter Haven Hospital]. Some

occasional variable decelerations were

present since early in labor. About 45

minutes before delivery the patient had

moderate vaginal bleeding and severe

variable decelerations that continued until

delivery. Cesarean section was done for the

abnormal FHR pattern. A uterine rupture was

documented at surgery. The fetal head was

in the maternal abdomen and the placenta was

completely separated from the uterus. No

cord blood could be obtained due to the

abruption. Birth weight was 3,329 grams or

7 lbs 5 ozs.

The newborn was floppy, depressed and had no

respiratory effort. [Apgar scores were

noted as 1, 5, and 7, at one, five, and ten

minutes respectively.] Bag and mask

ventilation was done until the heart rate

was >100 bpm. There was still no

respiratory effort and intubation was

required. The baby was taken to the NICU

intubated and with depressed muscle tone.

Initially, the baby did well, but shortly

after birth, an attempt to take the baby off

the ventilator failed. The baby became

acidotic and hypoxic. Seizure activity was

suspected based on facial grimacing. EEG

was normal. Re-intubation was required.

The baby remained on the ventilator for six

days.

Ultrasound of the head on the day after

birth was normal. MRI . . . [showed

abnormal signal within the thalami and basal

ganglia] suspicious of hypoxic insult. A

follow up MRI at 10 months of age was

normal. Genetic evaluation was done and was

normal.

* * *

In Summary, labor was complicated by a

uterine rupture due to a prior Cesarean

section. The baby was expelled into the

maternal abdominal cavity and the placenta

separated from the uterus. This event

resulted in oxygen deprivation to the baby

during labor, delivery and into the

immediate post delivery period with

resulting brain injury. I am not able to

comment as to the extent of the brain

injury.

(Joint Exhibit 7).

6. To address the nature and significance of Maritza's

injury, the parties also offered the report and deposition

testimony of Raymond Fernandez, M.D., a pediatric neurologist

who, at NICA's request, evaluated Maritza on November 12, 2008,

when she was a 3-year 1-month old infant. (Joint Exhibits 6 and

10). Based on his evaluation, review of the medical records,

and the history he obtained from Maritza's parents,

Dr. Fernandez, like Dr. Willis, was of the opinion that Maritza

suffered a brain injury (within the thalami and basal ganglia)

due to oxygen deprivation during labor and delivery, secondary

to uterine rupture. As for the significance of her injury,

Dr. Fernandez was of the opinion that Maritza's brain injury

rendered her permanently and substantially physically impaired,

but not permanently and substantially mentally impaired.

7. Pertinent to Maritza's impairments, Dr. Fernandez

documented the results of his evaluation, and Maritza's medical

history following her discharge from Winter Haven Hospital on

October 23, 2005, in his report, as follows:

An independent medical examination was

performed on 3-year 1-month-old Maritza Rios

on November 12, 2008, at the request of

Ms. Kathe Alexander, Florida Birth-Related

Neurological Injury Compensation

Association. Maritza was accompanied by her

parents, Mr. and Mrs. Rios.

* * *

Maritza was referred to a pediatric

neurologist on August 1, 2006, age 10

months, because of motor delay. She was not

sitting or crawling. She had strabismus and

was referred for physical therapy and

occupational therapy. Brain MRI on

August 21, 2006, reportedly was normal.

Also normal were amino acids, organic acids,

chromosomes, acylcarnitine profile, and

testing for Angelman syndrome was negative.

The next visit to pediatric neurology was on

September 26, 2006, age 11 months. She was

unable to sit, had mild tightness of heel

cords, stood with support on her tiptoes,

rolled over and said mama and papa. Plantar

responses were extensor. On December 19,

2006, age 14 months, personal-social

development was on target, fine motor

development was at the 10 to 11 month age,

language 14 months, and gross motor

development 7 months. It was stated that

lactate and ammonia were elevated. Muscle

biopsy showed congenital fiber type

disproportion but no details were given and

nonspecific Z-band streaming on electron

microscopy.

[On March 15, 2007, at] 17 months of age, [a

Speech-Language and Oral Motor Evaluation

noted] auditory comprehension was at the 14-

month level, and expressive communication

was at the 9-month level. [The evaluation

characterized Maritza's receptive language

skills as within normal limits [WNL] and her

expressive language skills as mildly to

moderately delayed. Speech therapy, at 30

minutes twice weekly for 6 months was

recommended. 3 ] At 1 year and 11 months of

age, gross and fine motor development was

said to be at the 12-month level.

Mr. and Mrs. Rios stated that Maritza was

generally healthy . They have not observed

seizures. They feel that she understands

what is said to her at an age-appropriate

level and that she interacts well with her

sisters. Speech, while initially delayed,

has improved significantly over the past 2

to 3 months. She now speaks numerous single

words, phrases and sentences, mainly in

Spanish. She sits independently but with a

rounded back and with her head often

deviated to 1 side or the other and

sometimes flexed onto her chest. Head

control is improving. She ambulates by

bouncing on her knees. She pulls to stand,

takes 2 or 3 independent steps and then

falls if not supported. She began doing

this about 2 months ago. Maritza has been

enrolled in a physical therapy program and

will begin an early learning program in

public school in January of 2009.

PHYSICAL EXAMINATION: Weight approximately

32 pounds. Pulse rate 92. Respiratory rate

20. Head circumference 48.5 cm (just below

the 50th percentile). Maritza was alert and

attentive. She was socially engaging. She

smiled responsively and extended her hand to

me when I greeted her. She told me her

first name and age when asked. She told me

her sisters' names. She also said in

Spanish that "I don't want to walk because I

cannot." Speech at times was indistinct

[dysarthric 4 ] but I was usually able to

understand her. She identified 2 colors

correctly, counted to 3 correctly, then

skipped 4 and then counted from 5 to 8. She

sang the alphabet song, although not

completely. She pointed to most body parts

correctly. She counted my fingers up to 3

correctly, then again skipped 4 and resumed

counting at 5. Maritza was visually

attentive and maintained good eye contact.

Pupils were equal and reactive to light.

Eyes were straight and moved fully. There

was no ptosis. Face was symmetric. Hearing

was grossly normal. Palate elevated

symmetrically. Tongue midline. She

swallowed well. There was no drooling.

Muscle tone was reduced axially and in her

limbs. She sat independently but with a

rounded back, and her head was either flexed

forward or deviated to either side. She

pulled to stand with difficulty and took 2

unsteady steps, and then would have fallen

if not supported. There was truncal

instability. There was no obvious weakness

of extremities in that she easily elevated

her arms above her head and elevated her

legs when on her mother's lap. Also, she

supported her weight when standing but was

unsteady, and I believe this is what would

have caused her to fall rather than weakness

of her legs. She reached with either hand

with tremor and with some writhing movements

of her arms distally. Deep tendon reflexes

were 1 in the arms, knees and ankles.

Plantar responses were probably flexor. ENT

exam was normal as were heart, lungs, and

abdomen. There were no dysmorphic features

or significant skin abnormalities. Maritza

stacked three 1-inch cubes, although with

difficulty because of her motor

incoordination. She attempted to draw

circles but had difficulty because of

tremor. She handed objects to either parent

correctly when asked to do so, and she also

placed objects on the examining table next

to her on request so that she understood

these verbal requests. She correctly named

pictures of animals and correctly described

a picture of ducks and stated in Spanish

that they were walking.

IMPRESSION: Motor impairment that is

substantial and consistent with deep brain

injury (with basal ganglia) due to oxygen

deprivation during labor and delivery,

secondary to uterine rupture. However, I do

not find evidence for substantial cognitive

impairment at this time. Please note that

Maritza might eventually prove to have

learning difficulty, but this cannot be

predicted based on current findings. She is

improving, and this trend should continue.

(Emphasis added).

(Joint Exhibit 6).

8. In his deposition testimony, Dr. Fernandez contrasted

the history he obtained and the results of his examination of

Maritza, with what he would expect to find if she were

substantially mentally impaired, as follows:

Well, a child with substantial cognitive

mental impairment is a child who is not

interactive, who is not attentive, who

doesn't comprehend or understand spoken

language, receptive language. A child that

cannot carry out verbal requests because

they don't understand what they are being

asked to do. A child who might not speak at

all. A child who doesn't understand, for

example, prepositional commands to give

something to that person, to give something

to the mother, to the father, put something

on the table. A child that cannot

understand that. A child who has not

learned and remembered colors at the age of

three years. That's a three-year-old

function. A child who cannot remember the

shapes of symbols like circles. That's a

three-year-old function, to know what a

circle looks like and to draw it, or try to

draw it in Maritza's case. She had trouble

because of the motor problem that she has,

but she made a definite attempt to make that

circle.

There are the things that a child with

substantial mental cognitive impairment are

not going to be able to do . . . .

(Joint Exhibit 10, p. 116). In contrast, Dr. Fernandez was of

the opinion that, by history and on evaluation, Maritza

interacted at an age appropriate level, by conversing,

understanding and following verbal requests; demonstrated

expressive and receptive language skills at an age appropriate

level; and had the ability to learn and be educated.

9. In response to the observations and opinions of

Dr. Fernandez, Intervenors offered the deposition testimony of

Mr. and Mrs. Rios, as well as the deposition testimony of

Elias Chalhub, M.D., a pediatric neurologist, to support a

conclusion that Maritza was permanently and substantially

mentally impaired. (Joint Exhibits 8, 9, and 11). However,

such testimony was not compelling.

10. From the testimony of Mr. and Mrs. Rios one learns

that Maritza does not know her numbers, or can count only to 2;

Maritza does not know the alphabet; Maritza knows only 3-5

words, but says more than 10; that six months earlier Maritza

spoke only 1 word; Maritza does not speak in sentences; Maritza

cannot converse; Maritza does not understand her parents;

Maritza does not understand the television shows she watches

(but, she watches in English, and speaks only Spanish); and

Maritza does not understand stories her parents may read to her

(but, they rarely read to her). However, Mr. and Mrs. Rios'

testimony conflicts dramatically with the history they provided

Dr. Fernandez, as well as Dr. Fernandez's personal and

professional observations, and no credible explanation was

offered to explain such discrepancy.

11. From Dr. Chalhub we learn that in his opinion Maritza

is permanently and substantially mentally impaired. However,

Dr. Chalhub did not examine Maritza, and in reaching his

opinion, Dr. Chalhub accepted, as true, the testimony of Mr. and

Mrs. Rios regarding Maritza's presentation, and rejected or

ignored the observations of Dr. Fernandez, without a persuasive

explanation.

12. Notably, the observations and opinions of

Dr. Fernandez were logical, consistent with the record, and not

shown to lack credibility. In contrast, the testimony of

Mr. and Mrs. Rios, as well as Dr. Chalhub, was not compelling.

Accordingly, it is resolved that, more likely than not, Maritza

is not permanently and substantially mentally impaired.

CONCLUSIONS OF LAW

13. The Division of Administrative Hearings has

jurisdiction over the parties to, and the subject matter of,

these proceedings. § 766.301, et seq ., Fla. Stat.

14. The Florida Birth-Related Neurological Injury

Compensation Plan was established by the Legislature "for the

purpose of providing compensation, irrespective of fault, for

birth-related neurological injury claims" relating to births

occurring on or after January 1, 1989. § 766.303(1), Fla. Stat.

15. The injured "infant, her or his personal

representative, parents, dependents, and next of kin," may seek

compensation under the Plan by filing a claim for compensation

with the Division of Administrative Hearings within five years

and 766.313, Fla. Stat. The Florida Birth-Related Neurological

Injury Compensation Association, which administers the Plan, has

"45 days from the date of service of a complete claim . . . in

which to file a response to the petition and to submit relevant

written information relating to the issue of whether the injury

is a birth-related neurological injury." § 766.305(3), Fla.

Stat.

16. If NICA determines that the injury alleged in a claim

is a compensable birth-related neurological injury, it may award

compensation to the claimant, provided that the award is

approved by the administrative law judge to whom the claim has

been assigned. § 766.305(7), Fla. Stat. If, on the other hand,

NICA disputes the claim, as it has in the instant case, the

dispute must be resolved by the assigned administrative law

judge in accordance with the provisions of Chapter 120, Florida

Statutes. §§ 766.304, 766.309, and 766.31, Fla. Stat.

17. In discharging this responsibility, the administrative

law judge must make the following determination based upon the

available evidence:

(a) Whether the injury claimed is a

birth-related neurological injury. If the

claimant has demonstrated, to the

satisfaction of the administrative law

judge, that the infant has sustained a brain

or spinal cord injury caused by oxygen

deprivation or mechanical injury and that

the infant was thereby rendered permanently

and substantially mentally and physically

impaired, a rebuttable presumption shall

arise that the injury is a birth-related

neurological injury as defined in s.

766.303(2).

(b) Whether obstetrical services were

delivered by a participating physician in

the course of labor, delivery, or

resuscitation in the immediate post-delivery

period in a hospital; or by a certified

nurse midwife in a teaching hospital

supervised by a participating physician in

the course of labor, delivery, or

resuscitation in the immediate post-delivery

period in a hospital.

§ 766.309(1), Fla. Stat. An award may be sustained only if the

administrative law judge concludes that the "infant has

sustained a birth-related neurological injury and that

obstetrical services were delivered by a participating physician

at birth." § 766.31(1), Fla. Stat.

18. Pertinent to this case, "birth-related neurological

injury" is defined by Section 766.302(2), to mean:

injury to the brain or spinal cord of a live

infant weighing at least 2,500 grams for a

single gestation or, in the case of a

multiple gestation, a live infant weighing

at least 2,000 grams at birth caused by

oxygen deprivation or mechanical injury

occurring in the course of labor, delivery,

or resuscitation in the immediate

postdelivery period in a hospital, which

renders the infant permanently and

substantially mentally and physically

impaired. This definition shall apply to

live births only and shall not include

disability or death caused by genetic or

congenital abnormality.

19. As the proponents of the issue, the burden rested on

Petitioners or Intervenors to demonstrate that Maritza suffered

a "birth-related neurological injury." See § 766.309(1)(a),

Fla. Stat. See also Balino v. Department of Health and

Rehabilitative Services , 348 So. 2d 349, 350 (Fla. 1st DCA

1977)("[T]he burden of proof, apart from statute, is on the

party asserting the affirmative issue before an administrative

tribunal.").

20. Here, the proof failed to demonstrate that Maritza was

"permanently and substantially mentally . . . impaired."

Consequently, given the provisions of Section 766.302(2),

Florida Statutes, Maritza does not qualify for coverage under

the Plan. See also Humana of Florida, Inc. v. McKaughan , 652

So. 2d 852, 859 (Fla. 2d DCA 1995)("[B]ecause the Plan . . . is

a statutory substitute for common law rights and liabilities, it

should be strictly construed to include only those subjects

clearly embraced within its terms."), approved , Florida Birth-

Related Neurological Injury Compensation Association v.

McKaughan , 668 So. 2d 974, 979 (Fla. 1996); Florida Birth-

Related Neurological Injury Compensation Association v. Florida

Division of Administrative Hearings , 686 So. 2d 1349, 1356 (Fla.

1997)(The Plan is written in the conjunctive and can only be

interpreted to require both substantial mental and substantial

physical impairment.).

21. Where, as here, the administrative law judge

determines that ". . . the injury alleged is not a birth-related

neurological injury . . . he [is required to] enter an order [to

such effect] and . . . cause a copy of such order to be sent

immediately to the parties by registered or certified mail."

§ 766.309(2), Fla. Stat. Such an order constitutes final agency

action subject to appellate court review. § 766.311(1), Fla.

Stat.

CONCLUSION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is

ORDERED that the claim for compensation filed by Hilda Rios

and Jaime Rios, on behalf of and as parents and natural

guardians of Maritza Rios, a minor, is dismissed with prejudice.

DONE AND ORDERED this 10th day of July, 2009, in

Tallahassee, Leon County, Florida.

WILLIAM J. KENDRICK

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

[phone]

Fax Filing [phone]

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 10th day of July, 2009.

ENDNOTES

1/ The Joint Exhibits are described, as follows: Exhibit 1

(Medical records of Winter Haven Hospital, October 10-22, 2005,

for Maritza Rios), Exhibit 2 (Medical records of Winter Haven

Hospital, October 9-13, 2005, for Hilda Rios), Exhibit 3

(Medical records of N. Nur Qureshi, M.D.), Exhibit 4 (Medical

records of Ricardo Arguello, M.D.), Exhibit 5 (Medical records

of Our Children's Rehab), Exhibit 6 (Medical report of Raymond

J. Fernandez, M.D., for an evaluation on November 12, 2008),

Exhibit 7 (Medical report of Donald Willis, M.D., dated

October 16, 2008), Exhibit 8 (Original deposition transcript of

Jaime Rios, taken March 25, 2009), Exhibit 9 (Original

deposition transcript of Hilda Rios, taken March 25, 2009),

Exhibit 10 (Original deposition transcript of Raymond J.

Fernandez, M.D., taken March 27, 2009), and Exhibit 11 (Original

deposition transcript of Elias Chalhub, M.D., taken May 13,

2009).

2/ Joint Pre-Hearing Stipulation; Transcript, pp. 4-7.

3/ Joint Exhibit 5.

4/ In Dr. Fernandez's deposition testimony he described her

speech as "dysarthric," and likely a motor issue as opposed to a

cognitive issue. (Joint Exhibit 10, p. 42). See also

"dysarthia," "imperfect articulation of speech due to

disturbance of muscular control which result from damage due to

the central or peripheral nervous system." Dorland's

Illustrated Medical Dictionary, 28th Edition, 1994.

COPIES FURNISHED :

(Via Certified Mail)

Kenney Shipley, Executive Director

Florida Birth Related Neurological

Injury Compensation Association

2360 Christopher Place, Suite 1

Tallahassee, Florida 32308

(Certified Mail No. 7008 3230 0001 6307 9579)

Armando T. Lauritano, Esquire

Morgan & Morgan, P.A.

One Tampa City Center

201 North Franklin Street, 7th Floor

Tampa, Florida 33602

(Certified Mail No. 7008 3230 0001 6307 9616)

John W. Bocchino, Esquire

Bobo, Ciotoli, Bocchino

Newman & Carsini, P.A.

Landmark Center One, Suite 510

315 East Robinson Street

Orlando, Florida 32801-1983

(Certified Mail No. 7008 3230 0001 6307 9623)

David W. Black, Esquire

Frank, Weinberg & Black, P.L.

7805 Southwest Sixth Court

Plantation, Florida 33324

(Certified Mail No. 7008 3230 0001 6307 9630)

Andrew M. Brown, Esquire

MacFarlane, Ferguson & McMullen

Post Office Box 1531

Tampa, Florida 33601-1531

(Certified Mail No. 7008 3230 0001 6307 9647)

Charlene Willoughby, Director

Consumer Services Unit - Enforcement

Department of Health

4052 Bald Cypress Way, Bin C-75

Tallahassee, Florida 32399-3275

(Certified Mail No. 7008 3230 0001 6307 9654)

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled

to judicial review pursuant to Sections 120.68 and 766.311,

Florida Statutes. Review proceedings are governed by the Florida

Rules of Appellate Procedure. Such proceedings are commenced by

filing the original of a notice of appeal with the Agency Clerk

of the Division of Administrative Hearings and a copy,

accompanied by filing fees prescribed by law, with the

appropriate District Court of Appeal. See Section 766.311,

Florida Statutes, and Florida Birth-Related Neurological Injury

Compensation Association v. Carreras , 598 So. 2d 299 (Fla. 1st

DCA 1992). The notice of appeal must be filed within 30 days of

rendition of the order to be reviewed.