National Maritime Center Medical Evaluation Board

seacap007 · January 14, 2011, 7:40am

This thread is for those Professional Mariners with medical waivers.
Very recently (5 days) I received a letter from NMC Medical Evaluation Board requesting “amplyfying information” regarding my physical for re-newal of documents. There were some 5 items listed which all but one has been reported each and every year since 2006. The requirements for retaining my documents were that I do a physical each year on the anniversary of my documents, and stipulated exactly what they wanted included in this physical. My Physician and I complied with each item listed in the letter, and a complete copy of that physical was sent to NMC every year.
Well in Oct of 2010 I submitted my application for renewal, it was accepted and then held over by the “Medical Evaluation Board”, By the way the item on the letter that was new, is a condition that was reported three years ago.
My documents expires next month, my frustration and question is why didn’t they request this information before now, and do you feel that the NMC should get into the business of conducting Physicals for all Mariners or should they be allowed to continue questioning the Mariners personal Physician… after all before a company hires a Mariner they must complete and pass a company’s physical… is this a case of “the chicken and the egg”.
Further frustrations… I am presently under contract with a company and on call, should they call me to go out to a vessel what can I tell them, that my license will expire in two/three weeks… they will think I’m irresponsible for letting that happen. With the job situation the way it is I feel the NMC is about to put men out of work.
Your thoughts please.

tugsri · January 14, 2011, 6:41pm

As someone who just finished renewing, I am here to tell you that this is only the beginning of a long drawn out affair with the Medical Evaluation Board if there are 5 Bullets on the Request. My Renewal Packet was received by the NMC on May 28, 2010 with a Document Expiration of Nov. 28, 2010. I Received my FIRST request for Amplifying Information Concerning 4 Specific Areas on June 10. Three of these included Diagnostic Testing. The NMC had the results of these tests on July 20. By August 4, the NMC Med Board wanted Further Information on the results of the previous tests. This also was provided. The first Week of September, another request for Amplifying Information was sent concerning the initial Request. Letters from 3 Doctors plus test results were sent to the NMC. On October 27, Yet Another Request was sent for “Amplifying Information”, this time for information not previously requested. I complied again. On November 19, I was sent a Regurgitation of All the Amplifying Information sent to the NMC with the notification that “A Decision Could Not Be Made At this Time” and more Information was needed and, I would Be sent a request for that information when it was determined just What was needed.

At this point, I contacted my State Representitives office concerning a MAJOR ISSUE with the NMC Medical Department, had 3 More letters from My Physicians Sent to the NMC and Called the NMC Daily trying to Get some Satisfaction. I got NO reponse from the NMC, but I think the Call to my Congressmans’ office ruffeled some feathers because I was contacted by my State Reps. office on November 24 That they had contacted the USCG Liasions office In the US House Of Representatives and I Recieved my License On November 27 by fed-ex with a medical waiver requiring annual testing for a non-existing physical condition.

Mine may be an extreme example, but be aware that the NMC Medical Department is not willing to take Your Physicians word on your over all health. I Wish you the best of luck!

hdblue · January 14, 2011, 11:32pm

[QUOTE=tugsri;45714]As someone who just finished renewing, I am here to tell you that this is only the beginning of a long drawn out affair with the Medical Evaluation Board if there are 5 Bullets on the Request. My Renewal Packet was received by the NMC on May 28, 2010 with a Document Expiration of Nov. 28, 2010. I Received my FIRST request for Amplifying Information Concerning 4 Specific Areas on June 10. Three of these included Diagnostic Testing. The NMC had the results of these tests on July 20. By August 4, the NMC Med Board wanted Further Information on the results of the previous tests. This also was provided. The first Week of September, another request for Amplifying Information was sent concerning the initial Request. Letters from 3 Doctors plus test results were sent to the NMC. On October 27, Yet Another Request was sent for “Amplifying Information”, this time for information not previously requested. I complied again. On November 19, I was sent a Regurgitation of All the Amplifying Information sent to the NMC with the notification that “A Decision Could Not Be Made At this Time” and more Information was needed and, I would Be sent a request for that information when it was determined just What was needed.

At this point, I contacted my State Representitives office concerning a MAJOR ISSUE with the NMC Medical Department, had 3 More letters from My Physicians Sent to the NMC and Called the NMC Daily trying to Get some Satisfaction. I got NO reponse from the NMC, but I think the Call to my Congressmans’ office ruffeled some feathers because I was contacted by my State Reps. office on November 24 That they had contacted the USCG Liasions office In the US House Of Representatives and I Recieved my License On November 27 by fed-ex with a medical waiver requiring annual testing for a non-existing physical condition.

Mine may be an extreme example, but be aware that the NMC Medical Department is not willing to take Your Physicians word on your over all health. I Wish you the best of luck![/QUOTE]

seacap007 · January 15, 2011, 8:33am

tugzri
that is useful information which lets me know not to wait until hell freezes over to take greater action.Your experience may prove to NOT be the extreme. This is almost like my last re-newal… I applied for my document in 2005 at an earlier date, I believe it was June, anyway “Katrina” came along and destroyed all the records at the New Orleans Exam Center (where I applied). Well I was scurrying around all over the place from Alaska to Miami to see if anyone had records of my history, along with a copy of my application. No one could tell me anything except, there was no central location where records are kept (I assume that is the logic behind establishing the NMC). After six months of nothing, I had to contact the Commandant of the District who got right on it and had my license and other documents within a week. Although “Katrina” was an act of nature the fact remains that a central location for Mariners records should have been in force long before now. My situation was so bad I began to panic because it had taken so long I was in the grace period.
If there are other Mariners out there with similar experiences, we should start a petition that would have NMC accept the results of Mariners personal physicians and test results, or begin doing physicals for the Mariners at no cost to the Mariner. I am sure this would be a costly and time consuming endeavor. But something needs to be done to stop this overreaching authority of the Medical Evaluation Board, and I do not believe it was the original intention of the Board to create such confusion.
One other note… I was not allowed to speak to anyone from the MEB, even though I was inquring about MY records. What a bureaurocracy. You can’t even ask about your own records.

sailaway · January 20, 2011, 6:28pm

The NMC medical department works like this-
Any positive responses on the 719K, no matter how seemingly insignificant , are sent to medical and looked over by a “screener”. If the problem is very simple ( you need glasses; you had your appendix out 20 years ago), the screener can sign off and that is it. If, and this is more often the case, the applicants medical history is more complex,( heart disease,pain meds, diabetes) it goes to an “evaluator”. (The evaluators at this time are usually PAs).
The evaluators are required to work by very strict guidelines as to what information is required. If it is not present, requests for “amplifying information " are sent out via snail mail. The mariner is supposed to take the letter to their physician(s) and let them handle the request. About 75% of the time the docs or PAs read the letter and send in what is required. If all is good then a waiver is issued. If not- and this is the way it is now- the file goes back to the shelf and sits until the application times out. Eventually the mariner calls in, and the call center will tell them they can arrange a conference call between the mariner, the physician, and an evaluator who let them know what is missing ( sometimes something as simple as a date that was omitted- often more complex). The rules forbid a mariner to speak directly to an evaluator. If the evaluator cannot issue a waiver because a health condition that does not meet NVIC regs ( most common- heart disease, uncontrolled diabetes, chronic pain meds, chronic tranquilizer use, chronic sleeping meds) the application goes to " second level review” at which time one of two physicians will make the final decision. If you are denied, there is an appeal process.
In a perfect world, a medical department would be efficient an organized and not have a large employee turnover and staff would not need to continually be in training. The private contractors would offer salaries and benefits comparable to what the government employees make to keep professionals around for more that a few months. The backlog would be weeks, not months. Those in charge would understand seasickness happens. Mariners would make firm but polite requests through the proper channels to change a system they though was burdensome and unfair…

dougpine · January 20, 2011, 10:45pm

Isn’t there something in the new Coast Guard Authorization bill that returns the decision making to your Physician? Or did I just dream that bit?

seacap007 · January 21, 2011, 9:18am

sailaway, this is very enlighting and thanks, I was pretty sure the evaluators were “PAs”, my question is why now, why not a heads up after receiving annual physicals for the prior years. You would think that a simple letter letting you know that you may be required to submit applying information in the future with regards to your last physical is “forthcoming”, this would allow one to collect the necessary amplying information well in advance. In other words, no suprises. This particular situation and the frustration that go with it would have been avoided. Maybe I’m overreacting… but it’s my livelyhood that concerns me.
Can you tell me this… Is this process only for originals and re-newals, Mariners on medical waivers (if like myself) have to submit a complete physical each year on the anniversary of Documents. Are they reviewing these physicals as well or just placing them in files. Because if they are reviewing them any discrepancies should be noted at the time of receipt and also made known to the Mariner in question. Is this a fair statement or opinion?

sailaway · January 23, 2011, 7:21pm

Seacap2007-
The medical review policies at the NMC have gone from very lax to fairly strict, mostly due to a change of the chief medical officer last year. If you are required to submit an annual medical waiver requirement, and it was issued a few years ago, the person now evaluating your file will likely choose to have it reflect current standards and that may require asking for “amplifying information” . Example- as recently as one year ago, mariners with sleep apnea just had to have a sleep study and a statement that they were being treated with CPAP- now, everyone on CPAP has to send in either their compliance data for the last 12 months (downloaded from the machine) or a Maintenance of Wakefullness Test ( which no one likes). Hopefully the waiver requirements that are given out now will state what needs to be submitted for the next year but as you see from the above, that is subject to change.
Dougpine, if there is a bill like that I haven’t heard about it. The way it is right now, unless NVIC regulations are fulfilled it dosen’t matter what someone’s personal physician says. Example- a physician says that their patient’s use of pain medications will not render them unsafe for duty - and that happens not infrequently- there is no way they will get approved.

dougpine · January 23, 2011, 10:06pm

Here’s what I’ve dug up from the bill so far. Note that 4 members of the committee are to by professional mariners. Keep your eyes out for the solicitation for applications to this committee.

SEC. 210. MERCHANT MARINER MEDICAL ADVISORY COMMITTEE.

(a) IN GENERAL.—Chapter 71 of title 46, United States Code,
is amended by adding at the end the following new section:

‘‘§ 7115. Merchant Mariner Medical Advisory Committee
‘‘(a) ESTABLISHMENT.—
‘‘(1) IN GENERAL.—There is established a Merchant Mariner
Medical Advisory Committee (in this section referred to as
the ‘Committee’).
‘‘(2) FUNCTIONS.—The Committee shall advise the Secretary
on matters relating to—
‘‘(A) medical certification determinations for issuance
of licences, certificates of registry, and merchant mariners’
documents;
‘‘(B) medical standards and guidelines for the physical
qualifications of operators of commercial vessels;
‘‘© medical examiner education; and
‘‘(D) medical research.
‘‘(b) MEMBERSHIP.—
‘‘(1) IN GENERAL.—The Committee shall consist of 14 mem-
bers, none of whom is a Federal employee, and shall include—
‘‘(A) ten who are health-care professionals with par-
ticular expertise, knowledge, or experience regarding the
medical examinations of merchant mariners or occupational
medicine; and
‘‘(B) four who are professional mariners with knowledge
and experience in mariner occupational requirements.
‘‘(2) STATUS OF MEMBERS.—Members of the Committee shall
not be considered Federal employees or otherwise in the service
or the employment of the Federal Government, except that
members shall be considered special Government employees,
as defined in section 202(a) of title 18, United States Code,
and shall be subject to any administrative standards of conduct
applicable to the employees of the department in which the
Coast Guard is operating.
‘‘© APPOINTMENTS; TERMS; VACANCIES.—
‘‘(1) APPOINTMENTS.—The Secretary shall appoint the mem-
bers of the Committee, and each member shall serve at the
pleasure of the Secretary.
‘‘(2) TERMS.—Each member shall be appointed for a term
of five years, except that, of the members first appointed, three
members shall be appointed for a term of two years.
‘‘(3) VACANCIES.—Any member appointed to fill the vacancy
prior to the expiration of the term for which that member’s
predecessor was appointed shall be appointed for the remainder
of that term.
‘‘(d) CHAIRMAN AND VICE CHAIRMAN.—The Secretary shall des-
ignate one member of the Committee as the Chairman and one
member as the Vice Chairman. The Vice Chairman shall act as
Chairman in the absence or incapacity of, or in the event of a
vacancy in the office of, the Chairman.
‘‘(e) COMPENSATION; REIMBURSEMENT.—Members of the Com-
mittee shall serve without compensation, except that, while engaged
in the performance of duties away from their homes or regular
places of business of the member, the member of the Committee
may be allowed travel expenses, including per diem in lieu of
subsistence, as authorized by section 5703 of title 5.

21:42 Nov 03, 2010

Jkt 099139

PO 00281

Frm 00009

Fmt 6580

Sfmt 6581

E:\PUBLAW\PUBL281.111

124 STAT. 2914

PUBLIC LAW 111–281—OCT. 15, 2010

Deadline.
14 USC 7115
note.

14 USC 7101.

‘‘(f) STAFF; SERVICES.—The Secretary shall furnish to the Com-
mittee the personnel and services as are considered necessary for
the conduct of its business.’’.
(b) FIRST MEETING.—No later than six months after the date
of enactment of this Act, the Merchant Mariner Medical Advisory
Committee established by the amendment made by this section
shall hold its first meeting.

OICUR12 · January 23, 2011, 10:58pm

morale of the story. when taking a physical for the cg or a company…even if there is somethin wrong with you…there ain’t nothin wrong with you. worry about the little white lies later. better to be workin than lost in some bureacratic pencil pusher pile of medical files.
what I tell my personal doctor and what I tell the company doctor are two totally different things.

tugsri · January 24, 2011, 5:25pm

What needs to happen with the Medical Evaluation Department within the NMC is hopefully being done with the Formation of the New Board.
For My renewal, I Had a 24 Hour Halter, A Nuclear Stress test, A Cardio Catherization and An Echo CardioGram, all ordered by the NMC, all showing NO signs of Cardiac Disease, Arterial Blockage or ANY issue with my Cardio-Vascular System.
I sent all Records from these tests, as well as reports from Three Cardiologists, to the NMC, yet the Medical Review Board REFUSED to Accept the findings and continued to ask for more “Amplifying Information” to answer questions already answered.
And while, as stated, you CAN request a Conference call with You, Your Physican and the NMC Doctor, I was Specifically told that there was “No Guarantee” the NMC Physician would be available to Speak with me and My Doctor when We Called and, I "could not make and Appointment with the Doctor."
If the Medical Evaluation Board is going to over-ride the findings of Medical Specialists when “Amplifying Information” is requested and Submitted, then there needs to be Specialists on the Medical Evaluation Board who are Able to Speak AND Understand the Language of the Applicants Doctors.
The Cardiology Practice I am a Patient of had Seriously Questioned the Abilities of the NMC Medical Evaluation Board Doctor as the Continued Requests for “Amplifying Information” were sent. They deal with Numerous Professional and Government Agency Medical Departments and the NMCs’ was, By far, the most frustrating and non responsive.
I understand and support the need for a thorough Medical Evaluation, but until such time as the NMC MEB can Honestly “Evaluate” Medical Issues,I say Know You are Healthy, But Keep any questionable issue to your self.

jdcavo · January 25, 2011, 5:32am

[QUOTE=dougpine;46169]Here’s what I’ve dug up from the bill so far. Note that 4 members of the committee are to by professional mariners. Keep your eyes out for the solicitation for applications to this committee… [/QUOTE]

This is the medical evaluation equivalent of TSAC and MERPAC. The committee was chartered almost two years ago. The inclusion in the 2010 Coast Guard authorization act is a prod from Congress to get the committee seated and to have a meeting (by April 15th). There was notice given to solicit members in approx. summer of '09 and the selections were referred to DHS for approval - it’s too late to get on this committee.

As with all advisory committees (MERPAC, TSAC, etc.), the committee will advise the Coast Guard on the medical issues and matters the Coast Guard refers to it. It will not evaluate individual mariners or their applications/fitness.

BMCSRetired · January 25, 2011, 6:27am

[QUOTE=jdcavo;46242]It will not evaluate individual mariners or their applications/fitness.[/QUOTE]

OK, I’ll ask the question; Is there a process for appealing a decision?

Steamer · January 25, 2011, 8:13am

[QUOTE=jdcavo;46242]As with all advisory committees (MERPAC, TSAC, etc …[/QUOTE]

Just for the record, MERPAC was disenfranchised at the same time the USCG came out with that incredible “recognise foreign certificates by making it legal to replace American officers on American flagged ships” idea.

Now, why, one might ask, would the CG do away with the only sea-going group chartered to provide real life industry input to its regulation making process at the same time it requested public input on such a profound change in US policy and law? After all MERPAC means (or used to mean) Merchant Marine Personnel Advisory Committee.

Using MERPAC as an example of a committee that will advise the CG is almost laughable. Probably almost as laughable as MERPAC would have considered the “recognition” idea … that is until they discovered it was not actually a joke.

I think it is time that merchant marine oversight was removed from the CG mandate and given back to DoT before it destroys what little remains of a future for the American mariner.

seadawg · January 25, 2011, 8:28am

[B][U]IMHO[/U][/B]…imagine that the process of (1) challenge (2) reconsideration and then (3) the appeal of the determination would apply…should involve a time consuming and costly process as your physican will need to get directly involved…should you suceed it is regretable that a mariner is unable to charge back to the NMC for their expenditure??

anchorman · January 25, 2011, 8:32am

[QUOTE=Steamer;46250]Just for the record, MERPAC was disenfranchised at the same time the USCG came out with that incredible “recognise” foreign certificates by making it legal to replace American officers on American flagged ships idea.

Now, why, one might ask, would the CG do away with the only sea-going group chartered to provide real life industry input to its regulation making process at the same time it requested public input on such an profound change in US policy and law? After all MERPAC means (or used to mean) Merchant Marine Personnel Advisory Committee.

Using MERPAC as an example of a committee that will advise the CG is almost laughable. Probably almost as laughable as MERPAC would have considered the “recognition” idea … that is until they discovered it was not actually a joke.

I think it is time that merchant marine oversight was removed from the CG mandate and given back to DoT before it destroys what little remains of a future for the American mariner.[/QUOTE]

The function of advisory committees should be advisory only, and that all matters under their consideration should be determined, in accordance with law, by the official, agency, or officer involved. Whether or not a committee is tasked, there is no legal obligation to take their recommendations regardless of Department.

Steamer · January 25, 2011, 8:37am

[QUOTE=anchorman;46254]The function of advisory committees should be advisory only …[/QUOTE]

Do you think that most native English speakers have a problem understanding the meaning of advisory?

anchorman · January 25, 2011, 8:42am

Only to the point that they disagree with it.

sailaway · January 25, 2011, 7:02pm

[QUOTE=BMCSRetired;46244]OK, I’ll ask the question; Is there a process for appealing a decision?[/QUOTE]

Yes, there is an appeal process but unless the denial was issued because of incomplete or inaccurate information, it will take someone with a lot of pull to reverse the decision. In some cases, a condition can be treated or a method of treatment changed in a way that will be viewed favorably. ( think stopping narcotic pain meds). In other cases- and coronary artery disease is a big one- [U]any[/U] degree of reversible ischemia on a stress test- no matter if you can run 10 miles , or what your cardiologist says- is considered unacceptable.

hdblue · January 26, 2011, 6:50pm

[QUOTE=hdblue;45719]<link rel=“File-List” href=“file:///C:%5CDOCUME%7E1%5CUser%5CLOCALS%7E1%5CTemp%5Cmsohtml1%5C01%5Cclip_filelist.xml”><!–[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]–><!–[if gte mso 9]><xml> <w:LatentStyles DefLockedState=“false” LatentStyleCount=“156”> </w:LatentStyles> </xml><![endif]–><style>  </style><!–[if gte mso 10]> <style> / Style Definitions */ table.MsoNormalTable {mso-style-name:“Table Normal”; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:“Times New Roman”; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]–> Hi,
<o></o>
Thanks very much for this comment. Very useful for me. Your points of view make me thinking about some thing for my project.

<!–[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]–><!–[if gte mso 9]><xml> <w:LatentStyles DefLockedState=“false” LatentStyleCount=“156”> </w:LatentStyles> </xml><![endif]–><!–[if gte mso 10]> <style> /* Style Definitions / table.MsoNormalTable {mso-style-name:“Table Normal”; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:“Times New Roman”; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]–> This link below can show more info, you can find them at: <!–[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]–><!–[if gte mso 9]><xml> <w:LatentStyles DefLockedState=“false” LatentStyleCount=“156”> </w:LatentStyles> </xml><![endif]–><!–[if gte mso 10]> <style> / Style Definitions */ table.MsoNormalTable {mso-style-name:“Table Normal”; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:“Times New Roman”; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]–>[B]Performance evaluation form[/B]

Topic		Replies	Views
Changes to medical processing at the National Maritime Center Professional Mariner Forum	17	3394	May 6, 2011
Renewal Timeline for USCG Medical Certificate: Maritime Training & Licensing	12	381	September 21, 2024
Hats off to NMC Professional Mariner Forum	5	1594	December 25, 2011
Notice to Mariners---Backlog at NMC Increasing Professional Mariner Forum	49	7241	June 9, 2009
Newest WtF from NMC Professional Mariner Forum	19	4254	September 15, 2016

National Maritime Center Medical Evaluation Board

Related topics