This report is designed to provide the Board of Registration in Medicine with a record of any disciplinary action taken by a professional organization (as defined below) against any person licensed by the Board of Registration in Medicine (i.e., a Medical Doctor or a Doctor of Osteopathy). Filing of this report is required by Chapter 112, section 5B of the Massachusetts General Laws. Communications with the Board, as required under this statute, are provided with certain legal protections. (See Chapter 112, section 5G.)
Forms
Instructions
Completing the Report:
Your responses should be typed or printed legibly. Please be brief but complete. If you need additional space, attach extra sheets. You should keep a copy of each report filed for your own records.
Filing the Report:
A report must be filed with the Board no later than 30 days after the actual imposition or initiation of a disciplinary action, whether or not the action has been or may be appealed. A separate report must be filed for each licensee disciplined and for each disciplinary proceeding.
When complete, reports should be sent by registered or certified mail to:
Data Repository Counsel
Board of Registration in Medicine
200 Harvard Mill Square, Suite 330
Wakefield, MA 01880
Who Must File:
The following entities are required to report disciplinary actions on this form: any professional medical association, society, body, professional standards review organization, or similarly constituted professional organization, whether or not such association, society, body, or organization is local, regional, national or international in scope.
Definition of "Disciplinary Action":
"Disciplinary action" includes, but is not limited to, revocation, suspension, censure, reprimand, restriction, non renewal, denial or restriction of privileges, or resignation. A denial or restriction of privileges or a resignation shall be reported only when the resignation or the denial or restriction of privileges is related in any way to (a) the applicant's competence to practice medicine or (b) a complaint or allegation regarding any violation of law or regulation, including but not limited to the regulations of the board, or hospital, health care facility or professional medical association by-laws, whether or not the complaint or allegation specifically cites violation of a specified law, regulation, or by-law [G.L. c.112. sec. 5B].
The Board appreciates your cooperation in completing and filing Professional Organization Disciplinary Action Reports. Please contact the Board's Data Repository Counsel at 781.876.8200 with any questions.