15-006204RP The Public Health Trust Of Miami-Dade County, Florida vs. Department Of Health Status: Closed DOAH Final Order on Friday, April 8, 2016.

Summary: Trauma center certification applicant did not have standing to challenge rules for creating trauma agencies that coordinate trauma systems. Alleged injury was speculative and not immediate.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

THE PUBLIC HEALTH TRUST OF

MIAMI - DADE COUNTY, FLORIDA,

Petitioner,

vs. Case No. 15 - 6204RP

DEPARTMENT OF HEALTH,

Respondent,

and

KENDALL HEALTHCARE GROUP, LTD ,

d/b/a KENDALL REGIONAL MEDICAL

CENTER ; AND O RANGE PARK MEDICAL

CENTER, INC ., d/b/a ORANGE PARK

MEDICAL CENTER,

Intervenors.

_______________________________/

FINAL ORDER

Administrative Law Judge John D. C. Newton, II, of the

Division of Administrative Hearings (DOAH) conducted the final

hearing on February 22, 2016, in Tallahassee, Florida.

APPEARANCES

For Petitioner : Thomas Francis Panza, Esquire

Paul Buckley, Esquire

Panza, Maurer & Maynard, P.A.

Bank of America Building, Third Floor

3600 North Federal Highway

Fort Lauderdale, Florida 33308

For Respondent: Daniel Ryan Russell, Esquire

Jones, Walker, Waechter, Poitevent,

Carrere and Denegre, LLP

Post Office Box 351

Tallahassee, Florida 32302 - 0351

Nichole Chere Geary, General Counsel

Department of Health

Bin A - 02

4052 Bald Cypress Way

Tallahassee, Florida 32399

For Intervenors: Stephen A. Ecenia, Esquire

J. Stephen Menton, Esquire

Gabriel F.V. Warren, Esquire

Rutledge, Ecenia and Purnell, P.A.

119 South Monroe Street, Suite 202

Post Office Box 551

Tallahassee, Florida 32302 - 0551

STATEMENT OF THE ISSUES

A. Doe s Petitioner, The Public Health Trust of Miami - Dade

County, Florida (Health Trust), have standing to challenge

Department of Health (Department) proposed rules 64J - 2.007,

64J - 2.008, and 64J - 2.009?

B. Is proposed rule 64J - 2.007 an invalid exercise of

dele gated legislative authority?

C. Is proposed rule 64J - 2.008 an invalid exercise of

delegated legislative authority?

D. Is proposed rule 64J - 2.009 an invalid exercise of

delegated legislative authority?

PRELIMINARY STATEMENT

This is a challenge, brought u nder the authority of

section 120.56, Florida Statutes (2015), 1/ to the validity of

three proposed rules of the Department. Health Trust filed a

Petition for Determination of Invalidity of Proposed Rules. The

petition challenges the validity of proposed rules 64J - 2.007,

64J - 2.008, 64J - 2.009, and 64J - 2.010. Three of those rules

regulate approval of trauma agencies. Kendall Healthcare Group,

Ltd. , d/b/a Kendall Regional Medical Center (Kendall Regional),

and Orange Park Medical Center, Inc., d/b/a Orang e Park Medical

Center (Orange Park), were granted leave to intervene.

After the parties conducted discovery, the Department

withdrew proposed rule 64J - 2.010. The validity of that proposed

rule is no longer an issue in this proceeding. The parties twice

s ought and obtained a continuance of the final hearing scheduled,

thereby waiving the time periods established by section

120.56(1)(c). By Order Granting Second Continuance and

Scheduling Pre - Hearing Conference, the undersigned scheduled the

final hearing for February 22, 2016. The final hearing convened

as scheduled.

Health Trust presented testimony from Leah Colston and

offered Exhibits 1 through 11 into evidence. The exhibits were

admitted. The Health Trust also offered as Exhibit 12 exce r pts

of the d eposition of Laura Hunter. Those excerpts along with

other excerpts , designated by the other parties for completeness ,

were accepted. The excerpts of the deposition admitted are:

page 5, line 5, through page 7, line 23

page 11, line 15, through page 13, line 2

page 12, line 6, through page 13, line 2

page 17, Line 2, through page 18, line 4

page 52, line 2, through page 55, line 12

page 59, line 15, through page 61, line 16

page 61, line 17, through page 62, line 18

page 65, line 7, through page 68 , line 1

page 66, line 9 through page 66, line 23

page 67, line 24, through page 68, 2/ line 1

page 97, lines 4 through 18

The Department, Kendall Regional, and Orange Park did not

otherwise offer evidence. The parties timely filed proposed

orders , whic h have been considered in the preparation of this

Final Order.

FINDINGS OF FACT

The Parties

1. Health Trust is an entity of Miami - Dade County. Health

Trust oversees the Jackson Health System, a health care provider

functioning as a three - hospital system . One hospital is Jackson

Memorial Hospital, a licensed acute care general hospital located

in Trauma Service Area (TSA) 19. It operates a verified Level I

trauma center, which is a part of the Miami - Dade County trauma

system. Health Trust also operates Jackson South Community

Hospital (Jackson South), a licensed acute care general hospital

in TSA 19.

2. There is no trauma agency in TSA 19. Health Trust is

not a trauma agency. It is not attempting to form or to be a

part of a coalition to form a trau ma agency for Miami - Dade

County.

3. Jackson South is committed to obtaining authority to

operate a Level II trauma center. In April 2015 , it applied to

operate a Level II trauma center. The Department denied the

application. Jackson South challenged th e denial and requested a

formal administrative hearing. The Department referred the

challenge to DOAH, where it was assigned Case No. 15 - 3171. Since

the hearing in this case, Administrative Law Judge John

Van Laningham issued an order recommending appro val of Jackson

SouthÓs application. 3/ As of the date of this O rder, the

Department has not issued a final order.

4. In September 2015, Jackson South submitted a trauma

center letter of intent to the Department expressing its intent

to become a Level II t rauma center in TSA 19. This was a

cautionary filing in the event the Department denies Jackson

SouthÓs first application now pending in DOAH Case No. 15 - 3171.

5. Kendall Healthcare is located in Miami, Florida. It is

a licensed acute care general hospi tal located in TSA 19.

Kendall Hea lthcare is a verified Level II trauma c enter.

6. Orange Park is located in Orange Park, Florida. Orange

Park is a licensed acute care general hospital located in TSA 5.

There is no trauma agency in TSA 5. Orange Park s ubmitted a

Trauma Center letter of i ntent to the Department in September

2015 , express ing its intent to file an application to become a

Level II trauma center.

7. The Department is the state agency authorized to verify

and regulate trauma centers and appr ove the establishment of

trauma agencies in the state of Florida. It published the

p roposed t rauma a gency r ules challenged in this proceeding.

The Florida Trauma System

8. Chapter 395, Part II, Florida Statutes , creates a plan

to establish an inclusive t rauma system to meet the needs of

trauma victims. § 395.40(2), Fla. Stat. The Legislature defined

Ðinclusive trauma systemÑ to mean Ða system designed to meet the

needs of all injured trauma victims who require care in an acute -

care setting and into whic h every health care provider or

facility with resources to care for the injured trauma victim is

incorporated.Ñ Id . The Legislature placed primary

responsibility for the planning and establishment of this

statewide inclusive trauma system with the Depart ment.

§ 395.40(3), Fla. Stat.

9. Section 395.402 establishes trauma service areas. One

component of the trauma system is the option for certain local or

regional organizations to form and operate trauma agencies to

plan, implement, and evaluate trau ma services systems in their

trauma system area. § 395.401(1)(a), Fla. Stat.

10. Section 395.4001(11) defines a Ðtrauma agencyÑ as Ða

department - approved agency established and operated by one or

more counties, or a department - approved entity with which one or

more counties contract, for the purpose of administering an

inclusive regional trauma system.Ñ According to Leah Colston,

Bureau Chief for the DepartmentÓs Bureau of Emergency Medical

Oversight, a trauma agency Ðis the coordinating body for all of

the emergency health care systems in a regional area that is

designed to evaluate the system and perform its improvement

opportunities to better outputs for patients.Ñ (Tr. 34, lines

22 - 25.)

11. Section 395.401 governs establishment of trauma

a gencies. It provides that the Department Ðmay approve or not

approve trauma agency plans based on the conformance of the plan

with [sections 395.401,] 395.4015, 395.404, and 395.4045 and the

rules and definitions adopted by the department.Ñ

§ 395.401(1)(c) , Fla. Stat .

12. There are four trauma agencies in Florida. One agency

covers 13 rural counties. The other three are for single

counties. The counties are Palm Beach, Broward, and

Hillsborough. There are no trauma agencies in TSA 19, which

covers Miami - Dade and Monroe Counties.

13. The last time the Department received an application to

establish a new trauma agency was in 1991. There is no dedicated

funding source for trauma agencies. They must find their own

funding. Absent a consistent funding source , how and where and

when future trauma agencies may develop is unclear.

Rulemaking Process

14. Over the past five years, there has been a considerable

amount of litigation about the DepartmentÓs rules governing the

allocation of the trauma centers around the state and

applications for new trauma centers.

15. In September 2011, Administrative Law Judge David

Watkins issued a Final Order invalidating Department rules

governing the allocation of trauma centers throughout the state.

The First District Cou rt of Appeal affirmed the Final Order. 4/

16. The Department pr oposed a new trauma allocation rule in

February 2014. Health Trust and other providers challenged that

rule. The rule was determined valid. 5/ Afterwards , several

providers applied for designati on as a trauma center in TSA 19,

including Jackson South.

17. After adoption of the new rule , the Department

undertook review of its trauma center rules, including the rules

pertaining to trauma agencies. This was part of the DepartmentÓs

compliance with it s rule reduction mandate. In an effort to

reduce the number of Department rules and to align the rules with

the statutory requirements, the Department promulgated the

proposed rules challenged in this proceeding. As Ms. Colston

explained, the Departme nt intended for the proposed rules to

align the rule requirements with the statutory provisions

governing the formation of a trauma agency and to delete

unnecessary or redundant information.

18. During the rulemaking process, the Department conducted

seve ral workshops. They were well - attended by representatives of

health care providers, including representatives of trauma

centers and emergency medical services providers. Health TrustÓs

representatives and legal counsel participated in the workshops.

1 9. The Department heard testimony and accepted written

comments from the public. The Department thoroughly reviewed the

public comments and considered them in finalizing the proposed

rules.

CONCLUSIONS OF LAW

20 . The Division of Administrative Hearings has

jurisdiction over the subject matter of this proceeding.

§§ 120.56(1)(a), 120.569 and 120.57(1), Fla. Stat.

Section 120.56(1)(a) provides:

Any person substantially affected by a rule

or a proposed rule may seek an administrative

determination of t he invalidity of the rule

on the ground that the rule is an invalid

exercise of delegated legislative authority.

21 . Jurisdiction attaches when a person who is

substantially affected by a proposed rule claims that it is an

invalid exercise of delegated l egislative authority. The party

challenging the proposed rule bears the burden of going forward.

The agency then must prove by a preponderance of the evidence

that the proposed rule is not an invalid exercise of delegated

legislative authority. § 120.56 (2), Fla. Stat.

22 . The Department, Kendall Regional, and Orange Park

maintain that Health Trust does not have standing to challenge

the proposed rules. Health Trust relies on its status as an

applicant for certification as a trauma center for its standi ng.

Health Trust must demonstrate that the proposed rules will

substantially affect it in order to prove standing.

§ 120.56(1)(a); Agrico Chemical Co. v. DepÓt of Envtl. Reg. , 406

So. 2d 478 (Fla. 2d DCA 1981).

23 . Ð[T]he law of standing is often hard to define and

subject to dispute.Ñ NAACP, Inc. v. Fla. B d . of Regents , 822 So.

2d 1, 14 (Fla. 1st DCA 2002)(dissenting opinion, Judge Browning),

reversed , 863 So. 2d 294 (Fla. 2003). But standing has its

limits. Fla. Soc. of Ophthalmology v. State Bd. of Optometry ,

532 So. 2d 1279, 1284 (Fla. 1st DCA 1988) . A party's substantial

interests are determined if: (1) the party will suffer injury in

fact which is of sufficient immediacy to entitle it to a section

120.57 hearing, and (2) the party's substanti al injury is of a

type or nature which the proceeding is designed to protect.

Agrico , 406 So. 2d at 482. The first prong of this test deals

with the degree of injury or "injury in fact." The second deals

with the nature of the injury. The Department, K endal Regional,

and Orange Park argue that Health Trust does not have standing

under this test because the injury asserted is not real and

immediate. It is instead hypothetical, conjectural and

speculative, and based on future events that may never happen .

24 . Determination of Health TrustÓs standing requires

analysis of a trauma agencyÓs role in the regulation of trauma

centers. Health Trust rests its claim for standing on specific

statutory provisions on the subject.

25 . Section 395.4025(1), Flori da Statutes, is one. That

statute charges the Department with responsibility for developing

a system of trauma centers. It says that the Department Ðshall

establish the approximate number of trauma centers neededÑ in

each TSA Ðbased on the state trauma s ystem plan, the local or

regional trauma services system plan, and recommendations of the

lo cal or regional trauma agency. Ñ The Department must develop

this allocation by rule. The validity of the DepartmentÓs rule

for developing the allocation is no lon ger at issue in this

proceeding. However, Health Trust has challenged the newly -

proposed allocation rule in Public Health Trust of Mi ami - Dade

County, Florida v. Departmen t of Health , DOAH Case

No. 16 - 001596RP. 6 /

26 . In order to be considered by the De partment, a would - be

trauma center Ðthat operates within the geographic area of a

local or regional trauma agency must certify that its intent to

operate as a trauma center is consistent with the trauma services

plan of the local or regional trauma agency. Ñ § 395.4025(2)(a),

Fla. Stat.

27 . The critical elements for a trauma center application

include Ðreview of whether the applicant hasÑ the necessary

equipment and physical facilities, sufficient qualified

personnel, an effective quality assurance process , and written

confirmation by the local or regional trauma agency that the

applicant is consistent with the trauma agencyÓs plan, Ðas

approved by the department, if such agency exists.Ñ

§ 395.4025(1)(c) , Fla. Stat .

28 . Ultimately , during the Departmen tÓs review of competing

trauma center applications, the trauma agencyÓs recommendation,

in a Department - approved plan, may serve as a Ðtie - breaker.Ñ

Florida Administrative Code Rule 64J - 2.016(11) currently says:

If the number of Provisional trauma centers

found eligible for selection by the

department in a given TSA exceeds the number

permitted, as provided in subsection 64J -

2.010(3) , [7 /] F.A.C. , the following criteria

shall be applied independently and

consecutively to all Provisional trauma

centers in th e TSA un til application of the

criteria results in the number of trauma

centers authorized in subsection 64J -

2.010(3), F.A.C., for that TSA. When that

occurs, the remaining cri teria shall not be

considered. The criteria to be applied are

as follows:

(a) A hospital recommended to be a trauma

center in the department - approved local or

regional trauma agency plan pursuan t to

subparagraph 64J - 2.007(2)(d)3., F.A.C., shall

be given approval preference over any

hospital which was not recommended.

29 . The que stion is: Is the secondary role of trauma

agencies in the DepartmentÓs review of trauma center applications

explicated above sufficient to create an injury in fact of

sufficient immediacy to support standing for Health Trust to

challenge the rules governi ng the establishment of the agencies?

It i s not.

30 . In every instance , it is the Department, not the

agency , that makes the decisions which may substantially affect a

trauma center applicant like Health Trust. The trauma agencies

are secondary and remo ved from any concrete decision. In

addition, all along the process, the decisions that Health Trust

claims may affect it, such as approval of trauma system plans or

trauma agency recommendations, are decisions separately subject

to challenge under section 120.569 as decisions affecting

substantial interests. Finally the ineluctable fact is that the

likelihood of a trauma agency being established in TSA 19 in the

foreseeable future is remote. Health TrustÓs theory for standing

rests on speculation and con jecture.

31 . The cases Health Trust relies upon do not involve facts

where the effect is as remote as presented here. None involve

challenges to a process for selecting a group permitted to make

comments or recommendations to a decision maker. A discuss ion of

representative cases follows.

32 . Professional Firefighters of Florida v. Departmen t of

Health & Rehabilitative Services . 396 So. 2d 1194 (Fla. 1 st DCA

1981) , involved changes in rules for certification as a paramedic.

The petitioning association represented firefighters who performed

paramedic functions in their employment as firefighters. The rule

changes required state certification as a paramedic and would have

made it illegal for the firefighters to continue performing

paramedic functions in their jobs . The First District Court of

Appeal easily found that people who would be prohibited from

continuing to perform their job duties by a rule change had

standing to challenge the rule change.

33 . Judge BoothÓs opinion noted the difference betwe en the

case and Department of Health & Rehabilitation Services v.

Alice P. , 367 So. 2d 1045, 1052 (Fla. 1st DCA 1979) , and Florida

Departmen t of Offender Rehab ilitation v. Jerry , 353 So. 2d 1230

(Fla. 1st DCA 1978), cert. denied , 359 So. 2d 1215 (Fla. 197 8),

in words appropriate here: ÐIn both Jerry and Alice P. , supra ,

the challengers were not subject to the rule or immediately

affected by it at the time suit was filed and were unlikely to be

affected in the future.Ñ ProfÓl Firefighters of Fla. V. DepÓt of

Health & Rehabilitative Servs . , 396 So. 2d 1194, 1196 (Fla. 1 st

DCA 1981).

34 . Health TrustÓs reliance upon the opinion of Coalition

of Mental Health Professions , 546 So. 2d 27 (Fla. 1st DCA 1989) ,

is also misplaced. That opinion, like the opinions i n

Professional Firefighters and Reiff v. Northeast Florida State

Hosp ital , 710 So. 2d 1030 (Fla. 1st DCA 1998), holds that parties

whose behavior a rule directly regulates or whose rights a rule

limits have standing to challenge the rule. The challenged r ules

in Coalition of Mental Health Professions Ðdefine[d] the

practices of clinical social workers, marriage and family

therapists and mental health counselors, respectively.Ñ Coal. of

Mental Health Professions , 546 So. 2d at 28 (Fla. 1st DCA 1989).

That substantially affected members of those mental health

professions.

35 . The DepartmentÓs proposed rules do not directly

regulate the behavior of Health Trust or limit its rights in the

way that the behavior and rights of the petitioners were affected

in P rofessional Firefighters and Reiff . The opinion in

Professional Firefighters has been discussed.

36 . Dr. Reiff was a licensed psychologist and Director of

Psychological Services at Northeast Florida State Hospital. He

challenged bylaws of the hospital Ó s Professional Staff

Organization because they had not been formally adopted. He also

challenged the by laws because they excluded psychologists from

obtaining clinical privileges to perform services that they were

authorized by the licensing laws to perf orm. The court reversed

a final o rder holding Dr. Reiff did not have stand ing. Reiff v.

Ne. Fla. State Hosp. , 710 So. 2d 1030 (Fla. 1st DCA 1998). It

held that the bylaws directly limited Dr. ReiffÓs rights. T he

proposed rules here do not directly, or even indirectly, limit

Health TrustÓs rights.

37 . Health Trust, citing Shands Jacksonville Medical

C enter , Inc. v. State , 123 So. 3d 86 (Fla . 1st DCA 2013), tries

to piggy back on the unchallenged, but inapplicable , proposition

that a determination of t he number of trauma centers permitted in

a TSA would affect would - be trauma centers in that TSA. That is

not this case.

38 . Parties do not have to prove immediate and ac tual harm

to establish standing, NAACP, Inc. v. Fla. Bd. of Regents , 863

So. 2d 294, 300 (Fla. 2003). But they have to show something.

This case involves rules that just do not have a real and

sufficiently immediate effect upon Health Trust. The record

demonstrates no effect that the proposed rules might have on

Health Trust. Its argu ments about how it may be affected are

speculation.

39 . Health TrustÓs speculation is much like the speculation

of the Jai - Alai Players Association in International Jai - Alai

Players Association v. Florida Pari - Mutuel Com munity , 561 So. 2d

1224 (Fla. 3d D CA 1990). The Association tried to contest an

application by jai - alai fronton owners to change opening and

closing dates, operation dates and make - up performance dates.

The Association claimed that the date changes would help fronton

owners in a labor di spute with the players. The court held that

the alleged injury was Ðfar too remote and speculative in nature

to qualify under the first prong of the Agrico standing test. Ñ

IntÓl Jai - Alai Players Ass'n v. Fla. Pari - Mutuel Com. , 561 So. 2d

at 1226 . The sa me applies to Health TrustÓs amorphous claims.

40 . Florida Society of Ophthalmology v. State Board of

Optometry , 532 So. 2d 1279 (Fla. 1st DCA 1988) , is another

instructive case. The Florida Society of Ophthalmology tried to

challenge Board of Optometry rules for certifying optometrists to

administer and prescribe some topical drugs. The theory was that

optometrists prescribing the drugs to patients would take

business, and therefore revenue, from ophthalmologists who would

otherwise have prescribed them . The court recognized that

ophthalmologists might suffer some economic injury because of

competition from optometrist s performing services that

ophthalmologists Ðalone were pr eviously permitted to perform. Ñ

Id. at 1285. But the potential injury did not satisfy the

ÐimmediacyÑ requirement.

41 . Health TrustÓs possible injury, whatever it may be, is

not immediate enough. Notably Health Trust has not identified

what injury might follow from the rules for creating trauma

agencies. How would one process as opposed to another result in

an agency more or less favorable to a Health Trust application?

Who could say? Health Trust does not. It just speculates that

there may be some injury.

42 . Standing under FloridaÓs Administrative Procedure Act

is broad. I t i s not and should not be limitless , as the opinion

in Florida Society of Ophthalmology , 532 So. 2d at 1284 ,

ob serves:

We initially observe that not everyone having

an interest in the outcome of a particular

dispute over an agency's interpretation of

th e law submitted to its charge, or the

agency's application of that law in

determining the rights and interests of

members of government or the public, is

entitled to participate as a party in an

administrative proceeding to resolve that

dispute. Were that not so, each interested

citizen could, merely by expressing an

interest, participate in the agency's efforts

to govern, a result that would unquestionably

impede the ability of the agency to function

efficiently and inevitably cause an increase

in the num ber of litigated disputes well

above the number that administrative and

appellate judges are capable of handling.

4 3 . Health Trust does not have standing to challenge the

DepartmentÓs proposed rules. There is no need to address the

arguments about the v alidity of the rules.

ORDER

Based on the foregoing Findings of Fact and Conclusions of

Law, it is ORDERED that the Petition for Determination of

Invalidity of Proposed Rules is DISMISSED.

Jurisdiction to determine entitlement to attorneyÓs fees and

costs a nd, if any , their amounts is reserved.

DONE AND ORDERED this 8th day of April , 2016 , in

Tallahassee, Leon County, Florida.

S

JOHN D. C. NEWTON, II

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tal lahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 8th day of April , 2016 .

ENDNOTES

1 / All citations to Florida Statutes are to the 2015 comp ilation

unless otherwise noted.

2 / The Order on Hunter Deposition Excerpts inadvertently and

incorrectly referred to page 67, line 24, through page 28,

line 1.

3 / Section 90.202, Florida Statutes, permits official

recognition of the status of the proc eeding.

4/ Bayfront Med. Ctr., Inc. v. DepÓt of Health , Case No. 11 - 2602RX

(Fla. DOAH Sept. 23, 2011)), affÓd , DepÓt of Health v. Bayfront

Med. Ctr., Inc. , 134 So. 3d 1017 (Fla. 1st DCA 2012).

5 / Shands Teaching Hosp. and Clinics, Inc. v. DepÓt of Heal th ,

Case No. 14 - 1022RP ( Fla. DOAH June 20, 2014).

6 / Section 90.202, Florida Statutes, permits official

recognition of the status of the proceeding.

7 / Rule 64J - 2.010 governs allocation of trauma centers among the

TSAs.

COPIES FURNISHED:

Thomas Fran cis Panza, Esquire

Panza, Maurer & Maynard, P.A.

Bank of America Building, Third Floor

3600 North Federal Highway

Fort Lauderdale, Florida 33308

(eServed)

Nichole Chere Geary, General Counsel

Department of Health

Bin A - 02

4052 Bald Cypress Way

Tallahasse e, Florida 32399

(eServed)

Abigail Price - Williams, Esquire

Miami - Dade County Attorney's Office

West Wing, Suite 108

1611 Northwest 12th Avenue

Miami, Florida 33136

Daniel Ryan Russell, Esquire

Jones, Walker, Waechter, Poitevent,

Carrere and Dene gre, LLP

Post Office Box 351

Tallahassee, Florida 32302 - 0351

(eServed)

Marc W. Dunbar, Esquire

Jones, Walker, Waechter, Poitevent,

Carrere and Denegre, LLP

Post Office Box 351

Tallahassee, Florida 32302

(eServed)

J. Stephen Menton, Esquire

Rutledge E cenia, P.A.

Post Office Box 551 (32302)

119 South Monroe Street, Suite 202

Tallahassee, Florida 32301

(eServed)

Stephen A. Ecenia, Esquire

Rutledge, Ecenia and Purnell, P.A.

119 South Monroe Street, Suite 202

Post Office Box 551

Tallahassee, Florida 323 02 - 0551

(eServed)

Gabriel F.V. Warren, Esquire

Rutledge Ecenia, P.A.

Post Office Box 551

Tallahassee, Florida 32301

(eServed)

Shannon Revels, Agency Clerk

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1703

(eServed)

Celeste Philip, M.D., M.P.H.

Interim State Surgeon General

Department of Health

4052 Bald Cypress Way, Bin A00

Tallahassee, Florida 32399 - 1701

(eServed)

Ernest Reddick, Chief

Alexandra Nam

Department of State

R. A. Gray Building

500 South Bronough Str eet

Tallahassee, Florida 32399 - 0250

(eServed)

Ken Plante, Coordinator

Joint Admin istrative Proced ures Committee

Room 680, Pepper Building

111 West Madison Street

Tallahassee, Florida 32399 - 1400

(eServed)

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is

entitled to judicial review pursuant to section 120.68, Florida

Statutes. Review proceedings are governed by the Florida Rules

of Appellate Procedure. Such proceedings are commenced by

filing the original not ice of administrative appeal with the

agency clerk of the Division of Administrative Hearings within

30 days of rendition of the order to be reviewed, and a copy of

the notice, accompanied by any filing fees prescribed by law,

with the clerk of the Distric t Court of Appeal in the appellate

district where the agency maintains its headquarters or where a

party resides or as otherwise provided by law.