By the Division of Professional Licensure

4.01: Scope of Practice

(1) A chiropractor who is duly registered with the Board may perform any and all procedures, functions and services which are included within the definition of "Chiropractic" as set forth in M.G.L. c. 112, § 89. Such procedures, functions and services include:

(a) Examining, evaluating, and diagnosing patients of all ages for the purpose of determining the presence or absence of neuromuscular and/or musculoskeletal illnesses, injuries, conditions or disorders which interfere with the biomechanical and/or neurological integrity or functioning of the human body including, but not limited to the vertebral subluxation complex;

(b) Ordering, performing and/or interpreting laboratory, radiological, electrodiagnostic or any other diagnostic studies for which the chiropractor has been appropriately trained by a college of Chiropractic which is accredited by the Council on Chiropractic Education, as defined in 233 CMR 2.01;

(c) Treating such neuromuscular and/or musculoskeletal illnesses, injuries, conditions or disorders through:

  1. the administration of Chiropractic adjustments or manipulations, either by hand or by instrumentation, to the body for the purpose of maintaining, restoring or improving biomechanical and/or neurological integrity or functioning in the human body;
  2. the administration, dispensing or prescribing of supportive procedures and therapies, as defined and set forth in 233 CMR 2.01 and 233 CMR 4.02; and
  3. the performance of any other therapeutic procedure or service for which the chiropractor has been appropriately trained by a college of Chiropractic which is accredited by the Council on Chiropractic Education, as defined in 233 CMR 2.01; and

(d) Counseling and instructing patients of all ages regarding health matters, including but not limited to the following: nutrition, supplementation, diet, exercise, activities of daily living, ergonomics, and good health habits.

(2) A chiropractor who is duly registered with the Board is an independent health care practitioner. A chiropractor is not required by law to perform such procedures, functions or services under the direction or supervision of, or upon referral from, any other health care professional, as long as he or she performs such procedures, functions and services in accordance with all applicable requirements of M.G.L. c. 112, §§ 89 through 97 and 233 CMR 2.00 through 4.00.

(3) Chiropractic examination procedures shall be consistent with the patient's subjective symptoms and objective findings, and shall be based upon a proper clinical rationale.

(4) The term "internal examination", as used in M.G.L. c. 112, § 89, shall mean a gynecological examination. A registered chiropractor shall not conduct or perform such internal gynecological examinations.

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4.02: Definition and Use of Supportive Procedures and Therapies

(1) For purposes of 233 CMR 4.00, the term "supportive procedures and therapies" means those modes of care which may be administered, dispensed or prescribed in addition to the primary Chiropractic procedure ( i.e., Chiropractic adjustments or techniques/manipulative techniques, as defined in M.G.L. c. 112, §§ 89, 94 and 97). Such supportive procedures and therapies include but are not limited to the use of braces, casting, supports, traction, thermal modalities, ultrasound, electrical modalities, hydrotherapy, myotherapy, dietary and nutritional advice and/or supplementation, and rehabilitative exercise therapy. The purpose of supportive procedures and therapies is to aid the chiropractor in assisting a patient to achieve a timely and favorable clinical outcome. A chiropractor shall not be required to apply supportive procedures and therapies in the practice of Chiropractic.

(2) All decisions made by a chiropractor regarding the use of supportive procedures and therapies shall be predicated upon a properly documented clinical rationale which is consistent with present educational and practice standards. The details of all supportive procedures or therapies provided shall be recorded when performed.

(3) The decision to use supportive procedures shall be based upon the clinical judgment of the chiropractor. Supportive procedures shall be used as a supplement to the primary Chiropractic procedure. However, if a chiropractor, in the reasonable exercise of his or her professional judgment, decides that a primary Chiropractic procedure is not prudent under the circumstances, he or she may properly apply any of the above supportive procedures or therapies for a reasonable time, if their use is clinically indicated and properly documented.

(4) No supportive procedure shall be administered unless a duly licensed chiropractor is on the premises.

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4.03: Limits on Delegation of Patient Care Functions

(1) A licensed chiropractor shall be responsible for all patient care provided by him or her, or by any of his or her agents or employees, and shall be responsible for any and all acts or omissions of such agents or employees.

(2) A licensed chiropractor shall not delegate any clinical function for which licensure, registration or certification is required under any other applicable provision of state law or regulations to any person who does not possess the appropriate license, registration or certification required by said law or regulation.

(3) A licensed chiropractor shall not delegate any of the following clinical functions to any person who is not duly registered to practice Chiropractic in the Commonwealth of Massachusetts:

(a) Performing any primary Chiropractic procedure as defined in 233 CMR 2.01;

(b) Initiating or altering any treatment plan or regimen without prior evaluation and approval by a licensed chiropractor;

(c) Modifying a specific treatment procedure without the prior approval of the licensed chiropractor;

(d) Interpreting clinical data or rendering opinions about such data; or

(e) Rendering opinions about a patient's current status or prognosis.

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4.04: Insurance Requirements for Limited Liability Companies and Limited Liability Partnerships

(1) A limited liability company or limited liability partnership which provides or offers to provide Chiropractic Treatment in Massachusetts shall maintain in good standing professional liability insurance which meets the following minimum standards:

(a) The insurance shall cover negligence, wrongful acts, and errors and omissions;

(b) The insurance shall insure the limited liability company and its members, as required by M.G.L. c. 156C, § 65, or the limited liability partnership and its partners as required by M.G.L. c. 108A, § 45(8)(a);

(c) The insurance shall provide, for each registered chiropractor who is a member, partner or employee of the limited liability company or limited liability partnership, coverage in an amount of at least $500,000 for each claim with an aggregate top limit of liability for all claims during any one year of at least $1,000,000; and

(d) The insurance required by 233 CMR 4.04(1) may provide that it does not apply to any dishonest, fraudulent, criminal or malicious act or omission of the insured limited liability company or limited liability partnership or any partner, member or employee thereof resulting in:

  1. Bodily injury to, or sickness, disease or death of, any person; or
  2. Injury to or destruction of any tangible property, including the loss of use thereof.

(e) Such insurance policies may contain reasonable provisions with respect to policy periods, territory, claims, conditions and other usual matters.

(2) A limited liability company or limited liability partnership which provides or offers to provide Chiropractic Treatment in Massachusetts is not required to maintain the insurance required by 233 CMR 4.04(1) if:

(a) That limited liability company or limited liability partnership maintains a designated and segregated capital fund equal to the amount of insurance required by 233 CMR 4.04(1)(c); and

(b) Such funds are specifically designated and segregated for the satisfaction of judgments against the limited liability company or its members, or the limited liability partnership or its partners, based on negligence, wrongful acts, or errors and omissions, by means of:

  1. Deposit in trust, or in bank escrow, of such funds in the form of cash, bank certificates of deposit, or United States Treasury obligations; or
  2. A bank letter of credit or insurance company bond.

(3) Upon any cancellation or other interruption in the insurance coverage required by 233 CMR 4.04(1), or any failure to maintain the designated and segregated capital fund required by 233 CMR 4.04(2), a limited liability company or limited liability partnership shall immediately cease providing or offering to provide Chiropractic Treatment until such time as the limited liability company or limited liability partnership is in compliance with 233 CMR 4.04.

(4) A limited liability company or limited liability partnership shall notify the Board in writing, within five business days, if the insurance coverage required by 233 CMR 4.04(1) is cancelled or otherwise interrupted, or if the designated and segregated capital fund required by 233 CMR 4.04(2) falls below the amount required by 233 CMR 4.04(2). Failure to provide such notice to the Board shall subject the members or partners of that limited liability company or limited liability partnership who are registered chiropractors to disciplinary action by the Board pursuant to 233 CMR 4.06.

(5) A limited liability company or limited liability partnership which provides or offers to provide Chiropractic Treatment may be required to provide satisfactory written verification of compliance with 233 CMR 4.04(1) or 233 CMR 4.04(2) at any time upon request by any duly authorized representative of the Board.

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4.05: Chiropractic Record-keeping

(1) A chiropractor shall establish and maintain a separate, adequate and accurate written clinical record for each patient in his or her care. The record shall be kept in chronological order and record entries shall be made contemporaneously. Each such entry shall be signed by, or shall otherwise adequately identify, the registered chiropractor who is treating the patient to whom the record pertains. Such records shall be legible and self-explanatory. Such records shall include, at a minimum, documentation of the following:

(a) The patient's case history;

(b) Findings of all examinations performed;

(c) Findings of special studies, including but not limited to x-ray studies taken or reviewed;

(d) Clinical impression

(e) Treatment plan;

(f) Informed consent;

(g) Progress notes for each patient encounter (Subjective and Objective Assessment and Plan format, Data Assessment and Plan format, or similar work chart notes); and

(h) Details of supportive procedures or therapies, when administered, dispensed or prescribed.

(2) Except as provided in 233 CMR 4.05(3) or (4), and 4.16 and 233 CMR 5.06 clinical records and all information contained therein shall be kept confidential to the extent provided by state or federal law.

(3) Upon the written request of the patient, the patient's authorized legal representative, or, in the case of an unemancipated minor patient, the patient's parent or legal guardian, a chiropractor shall furnish a complete copy of that patient's clinical records, including all supporting documentation and reports, to the party authorized to receive it. A reasonable fee may be charged for this service.

(4) A chiropractor shall furnish to the Board or its duly authorized representative a complete copy of a Patient Record upon written request. No fee may be charged for this service.

(5) No patient shall be required to sign any release from liability or waiver as a condition for the receipt of his or her clinical record pursuant to 233 CMR 4.05(3).

(6) Violation of any provision of 233 CMR 4.05 shall be considered unprofessional conduct within the meaning of M.G.L. c. 112, § 93, and shall constitute sufficient grounds for disciplinary action by the Board.

(7) Record Retention. Patient Records and Business Records shall be stored in a manner that protects them from foreseeable damage or destruction.

(a) Patient Records shall be maintained on the premises where Chiropractic Treatment is rendered for each active patient.

(b) Business Records shall be maintained for a minimum of seven years.

(c) For a patient who is younger than two years old when he or she receives Chiropractic Treatment, Patient Records shall be maintained at least until the patient reaches the age of nine.

(d) For a patient who receives Chiropractic Treatment on or after the patient reaches the age of two, Patient Records shall be maintained for a minimum of seven years from the date of the last patient encounter.

(e) Patient or Business Records stored electronically shall have an established system of weekly back-up. Copies of the back-up records shall be delivered weekly to an off-site location, where the back-up copies will be maintained in a safe and secure manner.

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4.06: Grounds for Disciplinary Action

The Board may, by majority vote after a hearing conducted in accordance with M.G.L. c. 30A and 801 CMR 1.00 et seq., take disciplinary action against any registered chiropractor who holds a certificate of registration issued pursuant to M.G.L. c. 112, §§ 89 through 97 and 233 CMR 2.00. Grounds for such disciplinary action shall include, but shall not be limited to:

(1) Conviction of any felony involving moral turpitude;

(2) Conviction of any other criminal offense which reasonably calls into question his or her fitness or ability to practice Chiropractic;

(3) Engaging in, authorizing, or aiding or abetting fraud, deceit, misrepresentation of material facts, provision of false or forged evidence, or bribery in connection with any application for a certificate of registration;

(4) Knowingly permitting, or aiding or abetting, an unlicensed person to perform activities which require registration as a chiropractor;

(5) Engaging in any practice or activity which is fraudulent or beyond the authorized scope of practice for a chiropractor;

(6) Engaging in negligent or incompetent practice, as defined in 233 CMR 4.07;

(7) Practicing while his or her ability to practice is impaired by alcohol, drugs, physical disability or mental illness;

(8) Being habitually intoxicated by, or engaging in the unlawful use of, alcohol, narcotics, barbiturates, amphetamines, hallucinogens or other controlled substances having similar effects;

(9) Engaging in, authorizing, or aiding or abetting, overutilization of practice, as defined in 233 CMR 4.08;

(10) Imposing, or authorizing the imposition of, improper charges for services, as defined in 233 CMR 4.09;

(11) Engaging in, authorizing, or aiding or abetting, fraud, misrepresentation or deceit in connection with his or her practice of Chiropractic, as defined in 233 CMR 4.10;

(12) Making any false statement or misrepresentation of material fact in connection with any application or claim for payment of any health care benefit, as defined in 233 CMR 4.11;

(13) Engaging in, authorizing, or aiding or abetting, any improper solicitation, inducement or referral, as defined in 233 CMR 4.12;

(14) Engaging in, soliciting, or otherwise attempting to engage in, any form of sexual relationship, activity or contact with a current patient, or with a former patient who has received a professional consultation, diagnostic service or therapeutic service within the past 90 days;

(15) Inducing, or attempting to induce, any patient to submit to any form of sexual relationship, activity or contact by falsely representing that the sexual relationship, activity or contact will or may be of diagnostic or therapeutic benefit to that patient;

(16) Engaging in gross misconduct in the practice of his or her profession as a chiropractor; or

(17) Practicing with a suspended or Expired license.

(18) Failing to cooperate with the Board or its agent with regard to inspections or investigations.

(19) Providing Chiropractic Treatment in an unlicensed facility where such facility is subject to the licensing requirements under 233 CMR 5.00.

(20) Failing to comply with 233 CMR and M.G.L. c. 112, §§ 61 through 65 and 89 through 97.

For purposes of 233 CMR 4.06, the term "disciplinary action" shall include, but shall not be limited to: denial, revocation or suspension of a certificate of registration; refusal to renew a certificate of registration; issuance of a letter of censure; issuance of a written reprimand; assessment of a civil administrative penalty; or placement of a registered chiropractor on probation.

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4.07: Negligent or Incompetent Practice

Negligent practice or incompetent practice shall constitute grounds for disciplinary action by the Board, regardless of the absence of injury or regardless of the degree of injury to the patient. Negligent or incompetent practice includes, but shall not be limited to:

(1) Grossly negligent practice, reckless practice, grossly incompetent practice, or intentional misapplication of practice on a particular occasion; or

(2) Negligent or incompetent practice on more than one occasion.

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4.08: Overutilization of Practice

(1) Overutilization of practice shall constitute "gross misconduct in the practice of the profession", within the meaning of M.G.L. c. 112, § 61, and "unprofessional conduct", within the meaning of M.G.L. c. 112, § 93, and shall constitute grounds for disciplinary action by the Board. Overutilization of practice is practice excessive in quality or amount to the needs of the patient. It may be determined from such sources as the patient's history, the patient's subjective and objective presentation, and reasonable clinical judgment as well as other relevant information.

(2) Any chiropractor who provides excessive treatment or issues excessive bills to a patient for the purpose of enabling the patient to incur medical treatment expenses in excess of the tort threshold established pursuant to M.G.L. c. 231, § 6D, shall be subject to disciplinary action by the Board. Such excessive treatment or excessive billing shall constitute "deceit" and "gross misconduct in the practice of the profession", within the meaning of M.G.L. c. 112, § 61, and "unprofessional conduct", within the meaning of M.G.L. c. 112, § 93. Such excessive treatment or excessive billing may also constitute a violation of 233 CMR 4.09, 233 CMR 4.10 or 233 CMR 4.11, and nothing in this section shall be deemed to alter or modify any other provisions of 233 CMR 4.00 et seq.

(3) For purposes of 233 CMR 4.08, "excessive treatment" shall include, but shall not be limited to:

(a) Treatment which exceeds, in quality or amount, the documented and clinically reasonable Chiropractic needs of the patient;

(b) Treatment which is unrelated to the diagnosed, or reasonably suspected, injury or condition incurred by the patient; or

(c) Treatment which is provided solely for the purpose of enabling the patient to incur medical treatment expenses in excess of the tort threshold established by M.G.L. c. 231, § 6D.

(4) For purposes of this section, "excessive billing" shall include, but shall not be limited to, bills for services which were not performed and/or bills which overstate the amount of time spent evaluating and/or treating the patient.

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4.09: Improper Charges

(1) Improper charges shall constitute a form of "deceit" and "gross misconduct in the practice of the profession", within the meaning of M.G.L. c. 112, § 61, and a form of "unprofessional conduct" within the meaning of M.G.L. c. 112, § 93.

(2) Charges for all services provided by a chiropractor shall be based on currently accepted and clinically appropriate procedure codes, including but not limited to Current Procedural Terminology (CPT) codes, or equivalent codes, and the relative value units ascribed to such codes.

(3) Without limiting the definition of improper charges, the following charges shall be considered improper charges:

(a) Charges for overutilization of practice, as defined in 233 CMR 4.08;

(b) Charges for adjustment/manipulation which are not based on currently accepted procedure codes;

(c) Charges which are based on a level of coding which is not consistent with the patient's clinical history, the subjective and objective clinical findings concerning the patient which were made at the time of the visit, the complexity of the clinical decision-making involved in the diagnosis and/or treatment of the patient, or the nature of the care provided to that patient;

(d) Charges for treatments, procedures or services which were not rendered, were not fully rendered, or were not rendered as represented by the charging chiropractor;

(e) Charges for any treatment, procedure or service which is provided to a patient on a particular office visit occurring on a particular day, if the charging chiropractor has advertised or proposed that any of his or her professional services will be provided free on that same day; or

(f) Charges billed to any third party payor for any service advertised as "free".

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4.10: Misrepresentation or Deceit

Without limiting the definition of misrepresentation or deceit each of the following claims if made by a chiropractor directly or by implication, shall constitute a form of misrepresentation and deceit:

(1) Claims that a chiropractor's professional qualifications differ from his actual qualification;

(2) Untrue claims that a chiropractor is affiliated with any institution, organization, or individual in a designated capacity;

(3) The use of any title other than "chiropractor", "doctor of chiropractic", "chiropractic physician", or "D.C.", to identify a chiropractor as a person lawfully entitled to practice Chiropractic in the Commonwealth;

(4) Performing, providing, or offering to perform or provide, any treatment, procedure or service which is beyond the proper scope of Chiropractic practice, as defined by M.G.L. c. 112, § 89 and 233 CMR 4.00, including but not limited to the use of harmonics, crystals, or colonic irrigation;

(5) Claims or representations that a particular treatment, procedure or service, or any combination of treatments, procedures or services, is guaranteed to result in a particular clinical outcome; or

(6) A chiropractor who only practices in a Solo Practice may not create the appearance as practicing in partnership with another Chiropractor.

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4.11: False Health Care Claims Prohibited

(1) The Board may take disciplinary action against a registered chiropractor, or a chiropractic facility pursuant to 233 CMR 4.06, if the registered chiropractor or any agent, servant or employee of the registered chiropractor or of the chiropractic facility makes any false statement or misrepresentation of material fact in connection with any application or claim for payment of any health care benefit.

(2) For purposes of 233 CMR 4.11 and 233 CMR 4.06, "making a false statement or misrepresentation of material fact in connection with any application or claim for payment of any health care benefit" includes, but is not limited to, any of the following:

(a) Making or causing to be made any false statement or misrepresentation of a material fact in any application for payment of a health care benefit;

(b) Presenting, or causing the presentation of, any application for a health care benefit which contains any false statement or misrepresentation of a material fact;

(c) Making, or causing the making of, any false statement or misrepresentation of a material fact for use in determining a patient's entitlement to any health care benefit, including whether particular goods or services were medically necessary in accordance with accepted standards of Chiropractic practice; or

(d) Concealing, or failing to disclose, the occurrence of an event which affects a patient's initial or continued right to any health care benefit for the purpose of enabling the patient to fraudulently secure that health care benefit either in a greater amount than is due or when no such benefit is due.

(3) A statement made in connection with an application or claim for payment of a health care benefit is false, within the meaning of 233 CMR 4.11, if it is wholly or partially false, fictitious, fraudulent, untrue or deceptive.

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4.12: Improper Solicitations, Inducements or Referrals

(1) No licensed chiropractor or agent, servant or employee of a licensed chiropractor or of a chiropractic facility shall offer, solicit or receive any remuneration, directly or indirectly, overtly or covertly, in cash or in kind, in return for purchasing, leasing, ordering, or arranging for any product, facility, service or item for any patient under his or her care.

(2) No licensed chiropractor or agent, servant, or employee of a licensed chiropractor or of a chiropractic facility shall offer, solicit or receive any remuneration, directly or indirectly, overtly or covertly, in cash or in kind, in return for recommending the purchasing, leasing or ordering of any product, facility, service or item for any patient under his or her care.

(3) No licensed chiropractor or agent, servant or employee of a licensed chiropractor or of a chiropractic facility shall offer or pay any remuneration, including any bribe or rebate, directly or indirectly, overtly or covertly, in cash or in kind, for the purpose of inducing any person to purchase, lease, order, or arrange for any product, facility, service or item related directly or indirectly to Chiropractic care, treatment or services.

(4) No licensed chiropractor or agent, servant or employee of a licensed chiropractor or of a chiropractic facility shall offer or pay any remuneration, including any bribe or rebate, directly or indirectly, overtly or covertly, in cash or in kind, for the purpose of inducing any person to recommend purchasing, leasing, ordering or arranging for any product, facility, service or item related directly or indirectly to Chiropractic care, treatment or services.

(5) Nothing in 233 CMR 4.12(1) through (4) shall be construed to prohibit any practice or arrangement which is specifically permitted under federal laws or regulations, including but not limited to 42 CFR 1001.952.

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4.13: Advertising

(1) A chiropractor or agent, servant or employee of a licensed chiropractor or of a chiropractic facility may properly advertise the services offered, but shall not engage in advertising which is false, deceptive, misleading or unfair.

(2) A chiropractor or chiropractor of record shall preserve a copy of each advertisement, and shall make a copy of the same available to the Board or its duly authorized representative upon request.

(3) Violation of any provision of 233 CMR 4.13 shall be considered "unprofessional conduct" within the meaning of M.G.L. c. 112, § 93, and shall be grounds for disciplinary action by the Board.

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4.14: Discriminatory Practices Prohibited

(1) A chiropractor or agent, servant or employee of a licensed chiropractor or of a chiropractic facility shall not refuse or restrict treatment of any person on the basis of race, color, religious creed, national origin, sex, sexual orientation, age, ancestry, marital status, status as a veteran or member of the armed forces, blindness, hearing impairment or any mental or physical disability or illness.

(2) A chiropractor or agent, servant or employee of a licensed chiropractor or of a chiropractic facility employing six or more persons in his or her practice shall not engage in any form of employment discrimination which is unlawful under M.G.L. c. 151B or any other applicable state or federal law.

(3) Violation of 233 CMR 4.14 shall constitute "unprofessional conduct", within the meaning of M.G.L. c. 112, § 93, and shall be grounds for disciplinary action by the Board.

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4.15: Advisory Rulings

Any interested person or his attorney may at any time request an advisory ruling with respect to the applicability to any person, property or factual situation of any statute or regulation enforced or administered by the Board. The request shall be addressed to the Board and sent to the secretary or Board clerk by certified mail or delivered in person during normal business hours. All such requests shall be signed by the person making it or his or her attorney, contain his or her address or the address of his or her attorney, and state clearly and concisely the substance or nature of the request. The request may be accompanied by any supporting data, views or arguments. Upon receipt of the request, the Board shall consider it and render its opinion in writing. When an advisory ruling is rendered, a copy of the ruling shall be sent to the person requesting it or his or her attorney. The Board may at any time rescind an advisory ruling.

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4.16: Solo Practice Inspections

The Board or its agent may inspect a Solo Practice any time during regular business hours, and without prior notice, for the purpose of verifying that the Solo Practice is properly excepted under 233 CMR 5.00: Chiropractic Facilities.

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REGULATORY AUTHORITY
233 CMR 4.00: M.G.L. c. 112, §§ 90, 94A and 96.