There is no specific form, but the report must be in writing. Please mail or fax it to:
Data Repository Counsel
Board of Registration in Medicine
200 Harvard Mill Square, Suite 330
Wakefield, MA 01880
Please explain in as much detail as possible the incident or circumstances causing you to file the report. Anonymous reports may be accepted; however, without specific information, the Board may be unable to investigate the allegations.
Most statutory and regulatory reports, including 5F reports, are reviewed by the Data Repository Committee (the "DRC"), currently comprised of two physician members of the Board. The DRC's role is to determine whether a formal investigation of the physician is necessary. In some circumstances, a report is referred directly to the Board's Enforcement Division for appropriate action.
The DRC may ask the physician for a response to the allegations contained in the report. Your 5F report will be paraphrased and your name will be redacted in DRC correspondence with the physician. DRC maintains the confidentiality of the reporter at this stage of the Board's review. Please be advised, however, that the identity of a reporter may not be withheld indefinitely, especially if the matter is referred to the Enforcement Division. Once the Board decides to bring charges against a physician, due process considerations allow him or her to know the identity of the reporter. In addition, in some cases that progress to a formal disciplinary proceeding, the Board may ask you to serve as a witness.
Often the DRC needs to obtain additional information, such as patient medical records, before making a final decision. Pursuant to Board regulations 243 CMR 1.02(8) (c) 5 and 243 CMR 1.03(14), Board records in connection with statutory reports are confidential, and therefore you may not be notified of a DRC or Board action taken on a report you file. Any such report that results in formal Board discipline, however, is a matter of public record and will be available on the Board's website. If the case is referred to the Enforcement Division, you may be contacted by a Special Investigator or by the Complaint Counsel assigned to the case.
If you have any questions about this process, or the status of your report, please call the Board's Data Repository Counsel at 781-876-8200.
Laws and Regulations
Please note that the statutory exception to the reporting requirement for impaired physicians applies only for physicians who are chemically dependent or impaired by alcohol. It does not extend to physicians impaired by physical or mental disorders.
In addition, you may wish to consult other laws and regulations, including the following: MGL c. 112 §§ 5, 5G(b); MGL c. 111 § 1; 243 CMR 1.03(5) and 243 CMR 2.07 (23).
This information is provided by the Board of Registration in Medicine.