STORAGE NAME: h1341a.HPP DATE: 4/11/2025 1 FLORIDA HOUSE OF REPRESENTATIVES BILL ANALYSIS This bill analysis was prepared by nonpartisan committee staff and does not constitute an official statement of legislative intent. BILL #: CS/HB 1341 TITLE: Health Care Practitioner Identification SPONSOR(S): Gonzalez Pittman COMPANION BILL: CS/CS/SB 172 (Burton) LINKED BILLS: None RELATED BILLS: CS/CS/SB 172 (Burton) Committee References Health Professions & Programs 13 Y, 4 N, As CS Health & Human Services SUMMARY Effect of the Bill: CS/HB 1341 regulates titles that health care practitioners may use to identify their profession to patients and the public. The bill establishes a list of 32 specialist titles that cannot be used by a physician unless the physician has been board-certified as such, and allows the Board of Medicine and Board of Osteopathic Medicine, to add other titles by rule. The bill expressly prohibits other non-physician health care practitioners from using any of the listed specialist titles. Violation of the prohibition constitutes unlicensed practice of medicine and DOH is authorized to pursue enforcement remedies against the practitioner. The bill also eliminates the requirement that a health maintenance organization (HMO) disclose the identity of the physician who has rendered an adverse determination regarding a service to the HMO subscriber and the treating provider. The bill instead requires that the HMO notify the subscriber that the adverse determination was made by a physician with an active, unencumbered license to practice medicine or osteopathic medicine in this state and maintain a record of each adverse determination, including the identity of the rendering physician. Fiscal or Economic Impact: The Department of Health will incur an insignificant, negative fiscal impact implementing the provisions of this bill which current resources are adequate to absorb. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY ANALYSIS EFFECT OF THE BILL: Health Care Professional Regulation Health care professionals are generally regulated by the Division of Medical Quality Assurance (MQA) under the Department of Health (DOH) in the interest of preserving the health, safety, and welfare of the public. 1 The MQA works in conjunction with profession-specific licensure boards and councils to license and regulate more than 40 different health care professions. 2 DOH licenses professions as established in law, but does not regulate practitioner use of common terms used to denote a practitioner’s specialty. The bill increases regulation of the ways in which health care practitioners represent their professions and identify themselves to patients. The bill revises the legislative intent underlying the state’s regulation of health care professions to place emphasis on the risks posed to the public when patients are misled about a practitioner’s authority to practice a profession. (Section 1). 1 S. 456.003(2), F.S. 2 Department of Health, Division of Medical Quality Assurance: Annual Report and Long-Range Plan, FY 2023-24 (2025). Available at https://www.floridahealth.gov/licensing-and-regulation/reports-and-publications/2024.10.28.FY23-24AR-FINAL.pdf (last visited April 7, 2025). JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 2 Specialist Titles Under current law, physicians licensed under chapter 458, F.S., or chapter 459, F.S., 3 may not present themselves as a board-certified specialist unless the physician has received formal recognition as a specialist by an appropriate certifying body approved by the Board of Medicine (BOM) or Board of Osteopathic Medicine (BOOM); however, current law does not identify specific titles that this provision applies to. 4 Furthermore, a health care practitioner must inform patients of the type of license under which they are practicing and are prohibited from making misleading, deceptive, or fraudulent representations in or related to the practice of the licensee’s profession. 5 The bill establishes a list of 32 specific “specialist titles and designations,” that are reserved for use by board- certified allopathic and osteopathic physicians, which include: • Surgeon. • Neurosurgeon. • General surgeon. • Anesthesiologist. • Cardiologist. • Dermatologist. • Endocrinologist. • Gastroenterologist. • Gynecologist. • Hematologist. • Hospitalist. • Intensivist. • Internist. • Laryngologist. • Nephrologist. • Neurologist. • Obstetrician. • Oncologist. • Ophthalmologist. • Orthopedic surgeon. • Orthopedist. • Otologist. • Otolaryngologist. • Otorhinolaryngologist. • Pathologist. • Pediatrician. • Proctologist. • Psychiatrist. • Radiologist. • Rheumatologist. • Rhinologist. • Urologist. (Sections 3 and 4). The bill authorizes the BOM and BOOM to, independently, adopt by rule additional specialist titles and designations that may not be used by a physician unless they have obtained the required board certification. (Sections 3 and 4). The bill prohibits non-physician health care practitioners from identifying themselves to patients or the general public with any of the 32 “specialist titles or designations,” specified in the bill. A health care practitioner who 3 Physicians licensed under ch. 458, F.S., are “allopathic physicians,” also known as medical doctors; physicians licensed under ch. 459, F.S., are “osteopathic physicians,” also known as doctors of osteopathy 4 Ss. 458.3312, F.S., and 459.0152, F.S. 5 S. 456.072, F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 3 violates this prohibition is considered to have engaged in the unlicensed practice of medicine, or osteopathic medicine, and DOH is authorized to pursue enforcement remedies against the practitioner. (Section 2). The bill specifies that a health care practitioner may identify themselves with the names and titles, and any corresponding designations or initials, that are expressly authorized in the practitioner’s respective practice act. Additionally, the bill outlines a specific manner which health care practitioners may use to identify themselves and use to describe their practice if the practitioner is practicing a specialty area that is authorized under the relevant practice act. Such a practitioner may identify themselves using the following formula: “… (name or title of the practitioner’s profession) …, specializing in… (name of the practitioner’s specialty) …” (Section 2). In addition to the titles authorized in each individual profession’s practice act, the bill specifies that certain health care practitioners may use other profession-specific titles as follows: Chiropractic physicians, licensed under chapter 460, F.S., may use the title “chiropractic radiologist,” as well as titles reflecting chiropractic specialty areas in which the chiropractic physician has attained diplomate status as recognized by the American Chiropractic Association, the International Chiropractors Association, the International Academy of Clinical Neurology, or the International Chiropractic Pediatric Association; Podiatric physicians, licensed under chapter 461, F.S., may use the titles “podiatric surgeon,” “Fellow in the American College of Foot and Ankle Surgeons,” as applicable; Dentists, licensed under chapter 466, F.S., may use the titles and abbreviations “doctor of dental surgery,” “D.D.S.,” “oral surgeon,” “maxillofacial surgeon,” “oral and maxillofacial surgeon,” “O.M.S.,” “dental anesthesiologist,” “oral pathologist,” “oral radiologist,” as applicable; and Anesthesiologist assistants, licensed under chapters 458, F.S., or 459, F.S., may use the titles “anesthesiologist assistant” or “certified anesthesiologist assistant” and the abbreviations “A.A.” or “C.A.A.,” as applicable. The bill specifies that the provisions established in the bill should not be construed to prohibit or interfere with a health care practitioner’s, group practice’s, or health care provider’s ability to lawfully bill Medicare or other federal health care program using definitions or terminology provided under applicable federal law or regulations for services rendered to enrolled patients. (Section 2). Physician Identity Disclosure Current law requires a health maintenance organization (HMO) to disclose the identity of the physician who has rendered an adverse determination regarding a service to the HMO subscriber and the treating provider. The bill eliminates the requirement that an HMO disclose the identity of the rendering physician. Instead, the bill requires an HMO to notify the subscriber that the adverse determination was made by a physician with an active, unencumbered license to practice medicine or osteopathic medicine in this state. The HMO must maintain a record of each adverse determination and identify the rendering physician in such record. (Section 5). The bill provides an effective date of July 1, 2025. (Section 6). RULEMAKING: The bill authorizes the BOM and the BOOM to adopt by rule additional specialist titles and designations which are subject to the restrictions established under the bill. Lawmaking is a legislative power; however, the Legislature may delegate a portion of such power to executive branch agencies to create rules that have the force of law. To exercise this delegated power, an agency must have a grant of rulemaking authority and a law to implement. FISCAL OR ECONOMIC IMPACT: JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 4 STATE GOVERNMENT: The Department of Health (DOH) will experience an increase in workload associated with the enforcement of this bill, which can be absorbed by current resources. 6 RELEVANT INFORMATION SUBJECT OVERVIEW: Health Care Practitioner Licensure and Regulation The Division of Medical Quality Assurance (MQA), within the Department of Health (DOH), has general regulatory authority over health care practitioners. 7 The MQA works in conjunction with 22 professional boards and four councils to license and regulate seven types of health care facilities and more than 40 health care professions. Every profession is regulated by ch. 456, F.S., which provides general regulatory and licensure authority for the MQA, as well as a profession- or field-specific practice act which outlines requirements and standards that vary by profession and establishes the individual professional boards. MQA is statutorily responsible for the following professional boards and advisory councils: 8 The Board of Acupuncture, created under ch. 457, F.S.; The Board of Athletic Training, created under part XIII of ch. 468, F.S.; The Board of Chiropractic Medicine, created under ch. 460, F.S.; The Board of Clinical Laboratory Personnel, created under part III of ch. 483, F.S.; The Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling, created under ch. 491, F.S.; The Board of Dentistry, created under ch. 466, F.S.; The Board of Hearing Aid Specialists, created under part II of ch. 484, F.S.; The Board of Massage Therapy, created under ch. 480, F.S.; The Board of Medicine, created under ch. 458, F.S.; The Board of Nursing, created under part I of ch. 464, F.S.; The Board of Nursing Home Administrators, created under part II of ch. 468, F.S.; The Board of Occupational Therapy, created under part III of ch. 468, F.S.; The Board of Opticianry, created under part I of ch. 484, F.S.; The Board of Optometry, created under ch. 463, F.S.; The Board of Orthotists and Prosthetists, created under part XIV of ch. 468, F.S.; The Board of Osteopathic Medicine, created under ch. 459, F.S.; The Board of Pharmacy, created under ch. 465, F.S.; The Board of Physical Therapy Practice, created under ch. 486, F.S.; The Board of Podiatric Medicine, created under ch. 461, F.S.; The Board of Psychology, created under ch. 490, F.S.; The Board of Respiratory Care, created under part V of ch. 468, F.S.; The Board of Speech-Language Pathology and Audiology, created under part I of ch. 468, F.S.; The Dietetics and Nutrition Practice Council, created under part X of ch. 468, F.S.; The Electrolysis Council, created under ch. 478, F.S.; The Council of Licensed Midwifery, created under ch. 467, F.S.; 6 Department of Health, 2025 Agency Bill Analysis: HB 1341 (2025). On file with the Health Professions & Programs Subcommittee. 7 Pursuant to s. 456.001(4), F.S., health care practitioners are defined to include acupuncturists, physicians, physician assistants, chiropractors, podiatrists, naturopaths, dentists, dental hygienists, optometrists, nurses, nursing assistants, pharmacists, midwives, speech language pathologists, nursing home administrators, occupational therapists, respiratory therapists, dieticians, athletic trainers, orthotists, prosthetists, electrologists, massage therapists, clinical laboratory personnel, medical physicists, dispensers of optical devices or hearing aids, physical therapists, psychologists, social workers, mental health counselors, and psychotherapists, among others. 8 Department of Health, Division of Medical Quality Assurance: Annual Report and Long-Range Plan, FY 2023-24 (2025). Available at https://www.floridahealth.gov/licensing-and-regulation/reports-and-publications/2024.10.28.FY23-24AR-FINAL.pdf (last visited April 7, 2025). JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 5 The Council on Physician Assistants, created under chs. 458 and 459, F.S. MQA also oversees the following seven health care professions for which there is no profession-specific regulatory board: 9 Certified Master Social Workers, as provided by s. 491.015, F.S.; Emergency Medical Technicians, as provided under part III of ch. 401, F.S.; Genetic Counselors, as provided under part III of ch. 483, F.S.; Medical Physicists, as provided under part II of ch. 483, F.S.; Naturopaths, as provided under ch. 462, F.S.; 10 Paramedics, as provided under part III of ch. 401, F.S.; Radiologic Technologists, as provided under part IV under ch. 468, F.S.; and School Psychologists, as provided under ch. 490, F.S. Practitioner Discipline Except for those professions for which there is no board, DOH and the professional boards have different roles in the regulatory system. Boards act as the governing body of a specified profession; they establish practice standards by rule, pursuant to statutory authority and directives, and determine disciplinary action against practitioners who have violated the practice standards. DOH receives and investigates complaints against practitioners and facilitates the legal response when necessary. DOH, on behalf of the boards, investigates legally sufficient complaints against practitioners. 11 Once an investigation is complete, DOH presents the investigatory findings to the boards. DOH recommends a course of action to the appropriate board’s probable cause panel 12 which may include having the file reviewed by an expert, issuing a closing order, or filing an administrative complaint. 13 The boards determine the course of action and any disciplinary action to take against a practitioner. 14 For professions that have no board, DOH determines the action and discipline to take against a practitioner and issues the final orders. 15 DOH is responsible for ensuring that licensees comply with the terms and penalties imposed by the boards. 16 If a case is appealed, DOH defends the board’s (or DOH’s) final actions before the appropriate appellate court. 17 Section 456.072, F.S., authorizes a professional board or DOH, if there is no board, to discipline a health care practitioner’s licensure for a number of offenses, including but not limited to: Making misleading, deceptive, or fraudulent representations in or related to the practice of the licensee’s profession; or Failing to identify through writing or orally to a patient the type of license under which the practitioner is practicing. 9 Id. 10 Id. There are currently no naturopaths actively licensed to practice in Florida. 11 Department of Health, Investigative Services. Available at http://www.floridahealth.gov/licensing-and-regulation/enforcement/admin- complaint-process/isu.html (last visited April 7, 2025). 12 See also, Department of Health, A Quick Guide to the MQA Disciplinary Process: Probable Cause Panels. Available at https://www.floridahealth.gov/licensing-and-regulation/enforcement/admin-complaint-process/_documents/a-quick-guide-to-the-mqa- disciplinary-process.pdf (last visited April 7, 2025) 13 Department of Health, Prosecution Services. Available at http://www.floridahealth.gov/licensing-and-regulation/enforcement/admin- complaint-process/psu.html (last visited April 7, 2025). 14 S. 456.072(2), F.S. 15 Id. Professions which do not have a board include naturopathy, nursing assistants, midwifery, respiratory therapy, dietetics and nutrition, electrolysis, medical physicists, and school psychologists. 16 Supra, note 13. 17 Id. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 6 Physicians are expressly subject to discipline for advertising a board-certified specialty for which they are not qualified. Using a term designating a medical specialty for which a non-physician practitioner has not completed a residency or fellowship program accredited or recognized by the Accreditation Council on Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) in such specialty is not expressly grounds for discipline under current law. 18 If the board or DOH finds that a licensee committed a violation, the board or DOH may: 19 Refuse to certify, or to certify with restrictions, an application for a license; Suspend or permanently revoke a license; Place a restriction on the licensee’s practice or license; Impose an administrative fine not to exceed $10,000 for each count or separate offense; if the violation is for fraud or making a false representation, a fine of $10,000 must be imposed for each count or separate offense; Issue a reprimand or letter of concern; Place the licensee on probation; Require a corrective action plan; Refund fees billed and collected from the patient or third party on behalf of the patient; or Require the licensee to undergo remedial education. The Unlicensed Activity Unit The Unlicensed Activity (ULA) Unit protects Florida residents and visitors from the potentially serious and dangerous consequences of receiving medical and health care services from an unlicensed person. The ULA unit investigates and refers for prosecution all unlicensed health care activity complaints and allegations. The ULA unit works in conjunction with law enforcement and the state attorney’s offices to prosecute individuals practicing without a license. In many instances, unlicensed activity is a felony level criminal offense. 20 The DOH assigns all ULA complaints a computer-generated complaint number for tracking purposes. If the allegations are determined to be legally sufficient, the matter will be forwarded to a ULA investigator whose office is geographically closest to the location where the alleged unlicensed activity is occurring. In cases where the person making the allegation has provided their identifying information, a ULA investigator will contact him or her to verify the allegations. The investigator may also ask for more detailed information concerning certain aspects of the complaint. He or she may also ask to meet with the complainant in person for a formal interview. All ULA investigators are empowered to take sworn statements. After discussing the allegations with the complainant, the ULA investigator will pursue all appropriate investigative steps (gather documents, conduct surveillance, question witnesses, etc.) in order to determine the likelihood that the offense(s) took place in the manner described by the complainant. In the event that a licensed health care provider is alleged to be somehow involved with the unlicensed activity, the ULA investigator will also coordinate his or her investigation with the Investigative Services Unit (ISU) regulatory investigator assigned to investigate the licensee. If the complainant’s allegations can be substantiated, the ULA investigation will conclude with one or more of the following outcomes: The subject(s) will be issued a Cease and Desist Agreement; The subject(s) will be issued a Uniform Unlicensed Activity Citation (fine); or The subject(s) will be arrested by law enforcement. 18 Ss. 458.331(1)(ll) and 459.015(1)(nn), F.S. 19 S. 456.073(1), F.S. 20 The Department of Health, Licensing and Regulation, enforcement, Unlicensed Activity, Reporting Unlicensed Activity. Available at https://www.floridahealth.gov/licensing-and-regulation/enforcement/report-unlicensed-activity/index.html (last visited April 7, 2025). JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 7 If the investigation determines that the alleged acts either did not take place or if they did occur but all actions were lawful and proper, the investigation will be closed as unfounded. In the event that the allegation(s) cannot be clearly proved or disproved, the matter will be closed as unsubstantiated. In any case, a detailed investigative report will be prepared by the ULA investigator supporting the conclusions reached by the investigation. Under s. 456.065, F.S., investigations involving the unlicensed practice of a health care profession are criminal investigations that require the development of sufficient evidence (probable cause) to present to law enforcement or file charges with the State Attorney’s Office in the county of occurrence. While ULA investigators are non-sworn, many have law enforcement experience gained from prior careers as police officers and detectives. ULA investigators work cooperatively with many law enforcement agencies in joint investigations that are either initiated by the DOH or the agency concerned. 21 Board Certification DOH licenses health care practitioners by profession according to the requirements established in statute and rule. Current law does not regulate practitioner use of use of common specialty terms such as “obstetrician,” or “pediatrician,” to indicate a specialized practice; instead the practice acts of individual professions recognize the authority of private national specialty boards for granting board certification to practitioners and prohibits the practitioner from holding themselves out as a “board-certified specialist,” unless the practitioner has received formal recognition as such. 22 An allopathic physician (M.D.) may not hold himself or herself out as a board-certified specialist unless he or she has received formal recognition as a specialist from a specialty board of the American Board of Medical Specialties (ABMS) or other recognizing agency 23 approved by the BOM. 24 Similarly, an osteopathic physician (D.O.) may not hold himself or herself out as a board-certified specialist unless he or she has successfully completed the requirements for certification by the AOA or the ACGME and is certified as a specialist by a certifying agency 25 approved by the BOOM. 26 A dentist may not hold himself or herself out as a specialist, or advertise membership in or specialty recognition by an accrediting organization, unless the dentist has completed a specialty education program approved by the American Dental Association and the Commission on Dental Accreditation and the dentist is: 27 Eligible for examination by a national specialty board recognized by the American Dental Association; or A diplomate of a national specialty board recognized by the American Dental Association. If a dentist announces or advertises a specialty practice for which there is not an approved accrediting organization, the dentist must clearly state that the specialty is not recognized or that the accrediting organization has not been approved by the American Dental Association or the Florida Board of Dentistry. 28 By rule, the Board of Chiropractic Medicine (BCM) prohibits chiropractors from using deceptive, fraudulent, and misleading advertising. The BCM permits chiropractors to advertise that they have attained Diplomate status in a chiropractic specialty area recognized by the BCM. BCM-recognized specialties include those which are recognized 21 The Department of Health, Licensing and Regulation, enforcement, Unlicensed Activity, Investigate Complaints, available at https://www.floridahealth.gov/licensing-and-regulation/enforcement/report-unlicensed-activity/investigate-complaints.html (last visited April 6, 2025). 22 Examples of specialties include dermatology, emergency medicine, ophthalmology, pediatric medicine, certified registered nurse anesthetist, clinical nurse specialist, cardiac nurse, nurse practitioner, endodontics, orthodontics, and pediatric dentistry. Examples of national specialty boards include The American Board of Medical Specialties and The Accreditation Board for Specialty Nursing Certification. 23 The Board of Medicine has approved the specialty boards of the ABMS as recognizing agencies. See, Rule 64B8-11.001(1)(f), F.A.C. 24 s. 458.3312, F.S. 25 The Board of Osteopathic Medicine has approved the specialty boards of the ABMS and AOA as recognizing agencies. See, Rule 64B15- 14.001(h), F.A.C. 26 S. 459.0152, F.S. 27 S. 466.0282, F.S. A dentist may also hold himself or herself out as a specialist if the dentist has continuously held himself or herself out as a specialist since December 31, 1964, in a specialty recognized by the American Dental Association. 28 S. 466.0282(3), F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 8 by the Councils of the American Chiropractic Association, the International Chiropractic Association, the International Academy of Clinical Neurology, or the International Chiropractic Pediatric Association. 29 Health Maintenance Organizations Health maintenance organizations (HMOs) provide, either directly or through arrangements with other persons, a comprehensive suite of health care services which subscribers are entitled to receive pursuant to a contract. 30 The Florida Insurance Code 31 prescribes the rights and responsibilities of health care providers, health insurers, and HMOs relating to the provision of services and the payment of claims. The law prescribes a protocol for specified providers to use for the submission of their claims to an insurer or HMO, as well as a statutory process for insurers or HMOs to use for the payment or denial of the claims. 32 HMOs are required to maintain an internal quality assurance program to ensure that the health care services provided to subscribers are rendered under reasonable standards of quality of care consistent with the prevailing standards of medical practice in the community. To such end, HMOs contract or employ physicians to conduct service utilization review and service authorization. Only a physician holding an active, unencumbered license issued under chapter 458, F.S., or chapter 459, F.S., may render an adverse determination regarding a service provided by a physician in this state. Current law requires an HMO to notify the treating provider and the subscriber of the adverse determination in writing. Such notification must include the utilization review criteria or benefits provisions used in the adverse determination, the identity of the physician who rendered the adverse determination, and be signed by an authorized representative of the organization or the physician who rendered the adverse determination. The notification must also include information on the appeal process for adverse determinations. 33 RECENT LEGISLATION: YEAR BILL # HOUSE SPONSOR(S) SENATE SPONSOR OTHER INFORMATION 2024 CS/HB 1295 Massullo Harrell The Senate bill died in House Returning Messages on March 8, 2024. 2023 CS/HB 583 Massullo Harrell The Governor vetoed the Senate companion on June 2, 2023. 2022 CS/CS/HB 861 Massullo Rodrigues The House bill died in House Returning Messages on March 14, 2022. 2021 CS/HB 721 Massullo Rodrigues The House bill died in the Senate on April 30, 2021. 29 Rule 64B-15.001(2)(e), F.A.C. Examples of chiropractic specialties include chiropractic acupuncture, chiropractic internist, chiropractic and clinical nutrition, radiology chiropractic, and pediatric chiropractors. 30 S. 641.19(12), F.S. 31 S. 624.01, F.S., chs. 624-632, 634, 635, 636, 641, 642, 648, and 651, F.S. 32 S. 641.3155, F.S. 33 S. 641.51, F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY 9 BILL HISTORY COMMITTEE REFERENCE ACTION DATE STAFF DIRECTOR/ POLICY CHIEF ANALYSIS PREPARED BY Health Professions & Programs Subcommittee 13 Y, 4 N, As CS 4/10/2025 McElroy Osborne THE CHANGES ADOPTED BY THE COMMITTEE: Removed provisions from the bill related to name tag and advertising requirements; Removed the requirement in current law that a health maintenance organization (HMO) must include the name of the physician rendering an adverse determination in the written notification to the subscriber and treating physician; and Required an HMO to include a written disclosure stating that the adverse determination was made by a Florida-licensed physician and requires the HMO to maintain a record of all adverse determinations including the identity of the rendering physician. Health & Human Services Committee ------------------------------------------------------------------------------------------------------------------------------------- THIS BILL ANALYSIS HAS BEEN UPDATED TO INCORPORATE ALL OF THE CHANGES DESCRIBED ABOVE. -------------------------------------------------------------------------------------------------------------------------------------