Subject Numbers Regarding Health Provider Authorizations

Authorization No. 186217-6W

June 30, 2014

Pursuant to Workers' Compensation Law Section 13-d(4), the Chair of the New York State Workers' Compensation Board has exercised his authority to temporarily suspend Dr. Thomas Gustafson’s authorization to treat injured workers within the New York State workers’ compensation system effective June 26, 2014. Dr. Gustafson's last known business address is 1243 Pennsylvania Avenue, Pine City, New York.

The Chair’s designee’s investigation revealed that the New York State Department of Health, State Board for Professional Medical Conduct (BPMC) issued Order # 13-420, wherein Dr. Gustafson did not contest the charge of having been convicted in Southport Town Court, Chemung County, New York of driving while intoxicated. As a result, Dr. Gustafson was penalized with a censure and reprimand, fined $1,000 and ordered to complete a Victim Impact Panel and the New York State Drinking Driver Program.

Therefore, the Chair believes that Dr. Gustafson may be guilty of misconduct, and that such misconduct would detrimentally affect the quality of care provided to injured workers.

Dr. Gustafson is prohibited from rendering treatment and care to injured workers while his authorization is temporarily suspended. Reports submitted by Dr. Gustafson for services rendered prior to June 26, 2014, are valid, but are invalid for any services rendered on or after that date. Requests to cross-examine Dr. Gustafson for services rendered prior to June 26, 2014 should not be denied due to the suspension of his authorization.

This suspension remains in effect until further notice. Any questions regarding the authorized lists should be referred to the Medical Director’s Office at 1 (800) 781-2362.