Professional Documents
Culture Documents
Before proceeding,
need copies for credentialing and other purposes. This completed renewal form with attachments sustst-henclarEerrilfe DV
u
I
rtLLJA LI I
green envelope 4 weeks before your renewal date.
Remit 5250.00 for renewal fee.
Add late fee of $25.00, if necessary.
Please review carefully the following information for accuracy and completeness. Make any corrections or
alterations as required.
I. Current Status:
Active
Registration No.:6049 1
If you want to change your current status, please check one of the following boxes to indicate your dew status: (Check only one)
Active
Other Name(s):
3 A) Mailing/Business Address:
ALAIN LESTER CAMPBELL
9 BOSTON STREET
SUITE 9
LYNN. MA 01904-0000
Mailing Address:
Citv/Town:
State:
Country:
Business Address:
City/Town:
Zip:
Country:
Business Telephone: (_ 5
544-7
B) Home Addrecc-
home Address:
Cityrfown:
Zip:
home Telephone:
Home Phone:
Business Phone:
State:
3.0120
State:
Country:
4. a) Date of Birth:
b) Sex:
c) SS#:
Faculty er
MlS:
1976
M.D.
4O
OBG
o
Obstetrics and Gynecology
0
10. Current health care facilities at which you have completed the credentialing process for the provision of patient care. (Supply
the codes front Table 3 and place a check mark next to those health care facilities where you have admitting privileges (AP).
Next to each facility, write the approximate percentage of patient usre hours that you provide in each facility).
Facility Code:5, 34 /
Facility Code: _ ___ /
If 999, print name(s):
-- (AP)
10 % Facility Code:_
(AP)
% Facility Code:
_/
/
(AP) _ %
(AP)
'N.
'PRO m UTujtL 4 I
b)
102-2-
.,
CI
B.
a) outpatient care
35.
2) What is the approximate percentage of your patient care hours in primary care?
5 hrstwb
5--
NH
14. CLAIMS MADE: Has any medical malpractice claim been made against you that has not yet been finally
settled or adjudicated, whether or not a lawsuit was filed in relation to the claim?
15. CLAIMS RESOLVED: Has any medical malpractice claim that has been made against you been settled,
adjudicated, or otherwise resolved, whether or not a lawsuit was filed in relation to the claim?
16. Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine,
or your professional conduct in the practice of medicine, been filed against you or been settled, adjudicated or
otherwise resolved?
17. Have you been charged with any criminal offense, other than a minor traffic violation?
18. Have you been charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of
any governmental authority, health care facility, group practice or professional society or association?
19. Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied,
restricted by, or surrendered to any state or federal agency?
20. Have you withdrawn an application for a medical license or been denied a medical license for any reason?
21. Has any professional liability insurance provider restricted, limited, torrninated imposed a surcharge or
co-payment, or placed any condition related to professional competency or conduct on your coverage or have
you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by a
professional liability insurance provider?
22. CME CERTIFICATION: Have you completed your CME requirements preceding your renewal date? [Yes
CME Waiver requested (CME waiver form due 30 days prior to date of license expiration)
No
CME exemption
See Instructions for CME requirements. Do not 'submit documentation of your CMEs with your renewal application.
Pursuant to G.L. c. 112, 2, I will not charge to or collect from a Medicare beneficiary more than the Medicare fee schedule amount.
Pursuant to G.L. c. 62C, 49A, to the best of my knowledge and belief, I have filed all Massachusetts state tax returns and paid all
Massachusetts state taxes that are required under law. NOTE: This applies even If you reside out-of-state or out of the United States.
Pursuant to CL c. 62C, 47A, to the best of my knowledge and belief lam in compliance with M.G.11.C. 119A relating to
withholding and remitting Child Support
Pursuant to C L. c. 712, IA, I will fulfill my obligation to report abuse or neglect of children as required by G.L. c. 119, 51A.
1 hereby certifi under the penalties of perjury that all She information on the Renewal Application and Form R is true.
Signature:
70,
Date:
DV 1/9
i 0/
YOU MUST SIGN AND INCLUDE PART B, WITH YOUR RENEWAL APPLICATION
Board Regulations require that you notify the Board, in writing, of any change of address
MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING.
I. Current Status:
If you want to change your current status, please indicate below: (Check one).
0 Active
3 A) Mailing/Home Address:
Mailing Address:
Zosroal S
Sag& 7
State ' MA
A.
.i-- Y./V Al
City/Town:
zip:
Home: t
Business: (
Home Phone:
Business Phone: (781)592-3000
Sex: M
country:
..
ilSii-
B) Business Address:
ATLANTICARE OB/GYN
9 BOSTON STREET
EAST LYNN, MA 01904
4. A) Date of Birth:
B) SS#:
0190V-
Sex :OM
Year Graduated:
Code(s)
0 F
Code:
Code:
Federal (DEA):
Mass:
Abbr:
Abbr:
If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts.
j.
Registration Number:
6099(
10. Current health care facilities at which you have completed the credentialing process for the provision of patient care. Supply
the codes from Table 3 and place a check mark next to those health care facilities where you have admitting privileges (AP). Next to
each facility, write the approximate percentage of patient care hours that you prove e in each facility.
S (Al')
Facility Code:
% Facility Code:__ yzi e./(AP)% Facility Code:_11
41 ir (AP) gig%
Facility Code:
/
(AP)
% Facility
/
(AP)
% Facility Code:
/
(AP)
If 999, print name(s):
1. My medical malpractice insurance is covered by a) grilisurance Carrier b) 0 Letter of Credit
Name of Theurer: hasAL r /Bra'. hts
ite /erns n 2( Alternatively, indicate as follows:
dhomee.
rn lc rte. m
1 am registering with Active status but I am not covered
/ by Medical malpractice insurance because I am (check one)
a) 0 Not involved in direct/indirect patient care in Massachusetts b) 0 Otherwise exempt
Please explain exemption:
12. Are you currently in a post-graduate training program in Massachusetts as a resident or clinical fellow? (check one) 0 Yes Efilsio
13. A. What is your principal work setting? (See Table 4) /
B. Care of patients in Massachusetts (see instruction booklet).
1)Average weekly hours involved in:
a) outpatient care
56 hrs/wk b) inpatient care 4- hrs/wk
2) What is the approximate percentage of your patient care hours in primary care? (0 'Ye
22. CME CERTIFICATION' Have you completed your CME requirements preceding your renewal date? 8/Yes 0 No
CME Waiver requested (CME waiver form due 30 days prior to date of license expiration) 0 Training Program exemption
See Instructions for CME requirements. Do not submit documentation of your CMEs with your renewal application.
Pursuant to G.L. e. 112, 2,1 will not charge to or collect from a Medicare beneficiary more than the Medicare fee schedule amount.
Pursuant to G.L. c. 62C, 49A, to the best of my knowledge and belief, I have filed all Massachusetts state tax returns and paid all
Massachusetts state toes that are required under law. NOTE: This applies even if you reside out-of-state or out of the United States.
Pursuant to G.L. c. 112, 1A, I will fulfill my obligation to report abuse or neglect of children as required by G.L. c 119, 151A.
I hereby cerd# under the penalties of perjury that all the information on the Renewal Application and Form R Li true.
Signature:
Date: 61
lal
79
YOU MUST SIGN AND INCLUDE PART B, PAGE 3, WITH YOUR RENEWAL APPLICATION
Copy this form and all attachments for your own records; you will need copies for credentialing and other purposes.
The Board will charge a fee for each copy.
Return renewal application in GREEN envelope.
Remit $250.00 for renewal fee.
Enclose check with coupon in BLUE envelope.
Add late fee of $25.00, if necessary.
Registration No.:
60491
I. Activity Status:
(Check only one)
Renewal Date:
['Active
0 Inactive *(see below)
04/28/97
0 Retiring (see instructions)
0 Do not wish to renew
Corrections (type or print)
..
Mailing Address:
State:
City/Town:
Zip:
Other Address:
City/Town:
B) Business Address:
ATLANTICARE OB/GYN
9 BOSTON STREET
LYNN, MA 01904
Home Phone:
Business Phone:
Country:
State:
Zip:
Country:
Home: (
Business: (
(617) 592-3000
)
)
C) Sex: 14
4. A) Date of Birth:
B) Lic. Issue Date: 10 /19/88 D) 5S14:
/
/
Sex (M/F):
55th
Code(s)
OBG
Degree (MD/DO): _
Year Graduated:
a CD
Code:
Code:
Federal (DEA):
Mass:
Abbr:
Abbr:
*If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts
CittA
P ?; LL-
0 4/qt
Registration Number:4
10.A. Current health care facilities at which you have completed the credentialing process for the provision of patient care. Supply the codes from
Table 3 and place a check mark next to those health care facilities where you have admitting privileges (AP).
Facility Code: Ct 02i /fr(AP)
Facility Code:____
(AP)
Facility Code:______/_(AP)
Facility Code:Q LE/iV(AP)
Facility Code_
Facility Code:______C(AP)
If 999, print name(s):
B. Additional health care facilities at which you previously held privileges or with which you were associated in the past two (2) years.
(See Table 3)
Facility Code:___
Facility Code:
Facility Code:
Insurance Carrier
b) Letter of Credit
d roAt-
ItilitaLCAIII OWc
Alternatively, indicate as follows: 1 am registering with Active status but I am not covered by medical malpractice insurance because
I am (check one) a)
Otherwise exempt
0 Yes Vigo
a) outpatient care
3 it
hrs/wk
2) What is the approximate percentage of your patient care hours in primary care ?
b) inpatient care
fa
hrs/wk
PART A
011ehtions 19 through 22 refer to the past two (2) years only. Check either YES or NO (NOT N/A) to each question. Provide
details on Form R for all YES answers extent for question 22. Refer to the instruction booklet for additional information and
definitions.
IN THE_PAST TWO 41 YEARS:
14,
YES
CLAIMS MADE: Has any medical malpractice claim been made against you that has not yet been finally settled or
adjudicated, whether or not a lawsuit was filed in relation to the claim?
IS. CLAIMS RESOLVED: Has any medical malpractice claim that has been made against you been settled, adjudicated, or
otherwise resolved, whether or not a lawsuit was filed in relation to the claim?
16. Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your
professional conduct in the practice of medicine, been filed against you or been settled, adjudicated or otherwise resolved?
17. Have you been charged with any criminal offense, other then a minor traffic violation?
18. Have you been formally charged with or disciplined for any violation of the rules, by-laws or standards of practice of any
governmental authority, health care facility, group practice or professional society or association?
19. Has your privilege to possess, dispense or prescribe controlled substances been surrendered to or suspended, revoked,
denied or restricted by any state or federal agency?
20. Have you withdrawn an application for a medical license or been denied a medical license for any mason?
21. Has any professional liability insurance provider restricted, limited, terminated, imposed a surcharge or co-payment, or
placed any condition related to professional competency or conduct on your coverage or have you voluntarily restricted,
limited or terminated your insurance coverage in response to an inquiry by a professional liability Insurance provider?
22. Have you completed your CME requirements preceding your renewal date (see instruction booklet)?
Waiver requested
See Instructions for CME requirements. Do not submit documentation of your CMEs with your renewal application.
RENEWAL APPLICATION CONTIN ED ON PAGE 3. ALL QUESTIONS ON PART B MUST BE ANSWERED.
Signature
Date:
6z- l 2r
94
Directions: Before proceeding, please read the instruction booklet. Some questions are optional.
Failure to renew in a timely manner will cause your license to lapse and may affect your
ability to practice medicine in the Commonwealth. (See enclosed letter).
Add late tee if necessary.
Make a copy of this form and all attachments for your own records - you will need copies for
credentialing and other purposes. The Board will charge a fee for each copy it provides.
See instructions on detachable coupon at bottom of this page.
Pre-Printed Information
I. Other name(s), if any, under which you were licensed:
2.
Business Address:
ATLANTICARE OB/GYN
493 WESTERN AVENUE
LYNN, MA 01904
'
06 alit)
ii-r-A-NTI
Name:
it ...4.,
--*
gAddress:
rod
City/Town:
Ail :
State:
Zip. .122LIELV---(.154
Country:
/
/
3. Date of Birth:
Sex: M
Lic. Issue Date: 10 /19/88 SSC
Jinnut Phnnr
ihntinMahigis
(617)592-3000
Home: (
/
/
Sex (WP):
SS#:
Business: (
Year Graduated:
Degree (MD/DO):
Degree: IC
7. If you are currently American Specialty Board certified, enter codes: (S ee Table 2)
Cade: 0G
8. Drug license number(s), if any:
Code:
a) Federal (DEA)
b) Massachusetts
Code:
Code:
Federal (DEA).
Mass.
INACTIVE
I hereby certify that if requesting Inactive status, I will not practice medicine, includbm writing prescriptions, In Massachusetts.
_L..=
san
Date:
oi /AS
ODZZ.UUVU
CAMPBELL
Last Name
Middle Initial
Sex
Atlanticare Ob/Gyn
225 Boston St,Suite 205
Lynn, MA 01904
U.S.A.
(617) 592-3000
1.114N
05.17.00
M.o.t 4 0
C61.1/ 5-ci
3.00.
Fit -Bic Es
AttikvaRia
ift.g.whutaff fr y tuf.o,tf
.17f.o1.Mattetink.s.kattcAlb
[Wes ETI No
IlidicaSehool
76
Date
MD
Degree
Residency Programs)
14.2 fir,
Potvinal of
lierscebilo
Residency Program(s)
III. SPECIALTY
End.iast 4-7
End --)U Non
BOARD CERTIFICATION
Certifying Board Name: Board of Obstetrics and Gynecology
Secondary Specialty:
Physician Profile
6622.001.1U
IV BOARD DISCIPLINE
Final Decisions and orders issued by the Massachusetts Board of Registration in Medicine.
Nature
Date
Board Action
V HOSPITAL DISCIPLINE
flovita)
DiQciplinary Action
Date
VII. MALPRACTICE
(q12
Awards, Honors
trobEarsitip, No-om tt Astifecil etypiert
Publications
oremibM
Physician Profile
60491
Status
Fee
ACTIVE $250.00
Renewal Date
04/26/93
Late Fee
$25.00
Mai ling
City/Town:
State.
Country Code (See Table 1).
2. a) Address (Home):
b) Address (Business):
ATLANTICARE 06/GYN
493 1.ESTERN AVENUE
LYNN, MA 01904
Zip.
If 999 print Country.
If 999 print Country:
3. Date of Birth;
Sex: fel
Lic. Issue Date: 1 / 19/68 Rs.:
Telephone Number
Business
1:19Elt
(617)592 - 3000
4. Name of Medical School:
Sex (M/F):
SSA:
Business: (
Year Graduated:
Degree (MD/DO):
Degree: M
t
Code
7. a) If you are currently American Specialty Board Certified, enter Codes (See Table 3)
Code: GG
Code:
b) If you previously were American Specialty Board certified, but are ni ilmtger.
please enter codes of prior certification: (See Table 3)
Code:
Code:
8. Drug License Number(s), if any: a) Federal (DEA)
b) State (MA)
Code:
Code:
Code:
Code:
Federal (DEA):
State (MA):
CA MP Bez-c
Registration Number:
6d Vf 1
10. Activity Status: I am applying to be registered with the following gams: Active
Inactive
I hereby certify that If requesting Inactive status, I will not practice medicine, including writing prescriptions, In Massachusetts.
11. My medical malpractice insurance is covered by (a) INSURANcE CARRIER or (13) LETTER OP CREDIT If applicable, check one.
NLE. Z0 (NT thild.gom. ASs .
\
A-.
List Insurer
a
Altenuitively, indicate as follows: I am registering with ACTIVE scams, but I ant not covered by medical malpractice insurance because I am
(Check One): (i) NOT INVOLVED IN DIRECT/INDIRECT PATIENT CARE IN MASS:
(ii) OTHERWISE EXEMPT:
(State how otherwise exempt):
12.Current Health Care Facility Affiliations, Supply the codes front Table 4 and place a check mark next to those facilities where you have
admitting privileges (AP).
AA
Facility Code:
(AP) Facility Code: _,(2
/1(AP)
Facility Code:
/
(Ap)
(AP) Facility Code:
Facility Code:
(AP)
Facility Code:
/
/
(Al')
(Check one)
US NO.
15.Has any medical malpractice claim been made against you, whether or not a lawsuit was filed in relation to the claim? ........,
16.Have you been charged with any criminal offense, other than a minor traffic violation?
17.Have you formally been charged with or disciplined for any violation of the rules, by-laws or standards of practice of any
governmental authority, health care facility, group practice or professional society or association?
18.Has your privilege to possess, dispense or prescribe controlled substances been surrendered to or suspended, revoked, denied
or restricted by any state or federal agency?
19.Have you withdrawn an application for a medical license or been denied a medical license for any reason?
20. Have you had any mental illness which has impaired your ability to practice medicine or to function as a student of medicine?
21. Have you had an organic illness which has impaired your ability to practice medicine or to function as a student of medicine?
22. Are you now, or have you been in the past two years, dependent upon alcohol or drugs?
23.Has any professional liability insurance provider restricted, limited, terminated or imposed a surcharge on your coverage?
Pursuant to G.L. c.1t2, sec. 2, I will not charge to or collect from a Medicare beneficiary more than the Medicare reasonable charges.
Pursuant to G.L. c. 62C, sec. 49A, I hereby certify under the penalties of perjury that, to the best of my knowledge and belief, I have
filed all Massachusetts state tax returns and paid all Massachusetts state taxes that are required under law. NOTE: This applies even if you
reside out-of-state or out of the country.
I hereby certify that I will fulfill my obligation to report abuse or neglect of children pursuant to G.L. c. 119, sec. MA.
I hereby certify under the penalties of perjury that all information on this form and Form ISA is true.
Signature:
Date.
Zit
/26/
43
Status
Fee
Renewal Date
00491 ACTIVE
$150
04/28/91
Dr. ALAIN LESTER CAMPBELL
/
I
Directions:
Quesfions l-7 include inkonation from Board filet. Please coma it as necessary.
Beim proceeding, please read the Instruction booklet
* Answer all non-optional questions completely. (The instnmeorm specify which questions are optional)
Make a copy of OS form ended attachments for your own records-you must give health owe facilites copies for aetientiefing purposes. The Board chvgn
$200 plus postage for each copy famished
. Enclose the $150.00 renewal fee by means of a certified check, money order or personal check made payable to the Commonwealth of Massachusetts.
Activity Status:
I am applying to be registered with the following status:
Active x x
Inactive_
I hereby certify that If requesting Inactive stews. I will not practice medicine In Massachusetts.
Pre-Printed Information
Name:
Address:
City/Town
State:
Country Code:
Address:
Cityfrovm:
State:
Country Code:
ATLANTICARE OS/GYN
493 WESTERN AVENUE
LYNN. MA 01904-
3. Date of Birth:
um issue Date: 10 /1 9 / 8 8
Zip:
(If ODD write Country):
Zip:
Of 999, write Country):
Sex: N
SSI4
&sines
( 17)592-3000
Home: (___)
Sex (WF):
T_____/
/
SSN il:
Telephone Number:
1391110
ID
Business: (
School Code:
if 99999, write School.
Year Graduated:
Degree (MD/DO):
03G
Hours her
gOi
In Mass
____ _.......
Coda:
Code:
Code:
Waiver Requested
I have completed my C.M.E. requirements In the two years emoting my renewal date:
YES X
(You must fill out a separate Waiver Form. 'The waiver must be granted by the Board before your license wit be renewed.) See instructions for OME
requkements. Do not submit documentation of your OME's with your renewal application.
( For Office Use Only: Waiver Granted
som - 9/90 - P813971
Date:
/_ )
10. My medical malpractice Insurance is covered by (a) INSURANCE CARRIER xx or (b) LETTER OF CREDIT
11. Current Hospital Affiliations (Supply the codes from Table 5 and plate a ohm* mark next to those Mallfres where you have admitting privileges (AP).
Facility Code: 008 Pc )(AP)
Facility Code:
L(AP)
Facility Code:S.1_4_60MP)
FacliW Code: _
tJAP)
III
/42
18. Have you been a defendant in any pending or new criminal proceedng other than a minor traffic unser
17.Are any formal deddinary charges pending or has any disciplinary action (as defined by Board regulationsSee instructions) been taken
against you by any governmental authority, hospital or other health care faddy, or professional medical association (international, national,
state or lord)?
18.Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied, rented, surrendered,
or have you been called before or been warned by this state or any other furisdctIon inoludng a federal agency?
19.Have you withdrawn an application for a medical license or been denied a medal! license for any reason?
20.Have you had any mental Illness which has Impaired your ability to practice medicine or to function as a student of medcine?
21.Have you had an organic illness which has impaired your ability to practice medicine or to function as a student of medicine?
22. Are you now, or have you been in the past four years, dependent upon alcohol or drugs?
Pursuant to WO,L. oA76, I will not okays to or collect from a Medicare beneficiary more than the Medicare reasonable chugs for my ithinfIces.
Pursuant to M.G.L. od2C aeo.49A, I unify under the penalties of perjury that, to my best knowledge and belief, I have Mad any Massachusetts state
tax returns and paid any Massachusetts state taxes, that are required under law. NOTE: This applies even if you reside outshatate or out of the
isountry.
I certify that! will fulfill my obligation to report abuse or neglect of children pursuant to M.G.L. 0.119 sec.61A.
I hereby certify under the penalties of perjury that all Information on this form and Form lliA b true.
Signature:
Date
V (77"///
54, ed re&
C
HE COMMONWEALTH OF MASSACHUSETTS
ARD OF REGISTRATION AND DISCIPLINE IN MEDICINE
Application for Endonement Registration
(Fee
vo X
F ed
s,
Application #
(14k
F-mm a Fee
Certificate #
Pease Print
Lester
Alain
pint
Date of Birth
Na me
Date of Issum
SWORN STATEMENT
Dam , March 11th, 1988.
CAMPBELLAddress7375 de Dieppe Ave.,
Waddle
lar
Montreal, Quebec, Canada.
Quebec, Can a d a
H3R 2T6
PreMedical Education
Medical Education
McGill University
School
B.Sc. : 1969-72
us Attended
1972-76 M.11
Place
C.M.
Dater
MpGil
monl. 1 Univ and Univ. Mt1; 1977-80
pro
Appointments: Assistant Prof Cl into al OB/GYN- , frac -Neale zne and
Leal, 9-Lc itesti..e and ilatia.1 -Ri P11
Graduate Situates, univList all other states in which you have been fully licensed.
t 1 n ivprsitv Hotpitals; 1981-actual 1988;
QUEBEC, only, Canada 7]-182
Residency
none
List Specialty Boards by which you are certified. AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY
icg
04244-4 tre\COM
&1/4-
lrt
1/4/4 itecat..4
n. iCeia Ata-W4
oalmw
1k4 m-
Ifrcfrot_44:AM.
es"-- 02),
D6/(Y$
tt
1-aAkm.
(
kg- &PAR.
14 k`iialLela3/4 Jr:clumutok &aa. CA-at 616113
4124,0*g%'" AvjL
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1.144:
al-
f r1983
4 1:ATirs4SAI
(
-A
-)Ci"
4C,_ AA 16 .
OUX
41"
te"le C'OYIONWIALTH OF MASSACHUSETTS
mr
H31.
18.
111 NO
NOTE ON QUESTIONS 1S-17: The harm that befalls physicians and patient. alike when
impairment goes undetected and untreated by the medical profession is devastating.
The bard wants Impaired physicians treated in the early stages of impairment before
irreparable harm to the physician or patient occurs.
If you have answered "yes" to any of the above except 118 please explain on Alie
reverse side. Attach additional 8 1/2" x 11" sheets if necessary.
I will read
the Board's regulations, 243 CNR 1.00 through 3.00. To the best of my knowle'4%S
I meet the qualifications for Full Licensure in Massachusetts.
I hereby certify under the penalty of perjury that all information on this form
(front and back) including attached sheets is true.
SIGNATURE:
DATE:
MaAA
thmib
008264 41Zf
Status
Fee
1150
Renewed Date
04/20/89
M.R.
Pr.
Bk.
Ch.
D.E.
R.
, lait sqt
1;
Important
.Read me accompanying instructions In their entirety before completing this form. Do not delegate this Important task to an employee, as false IgelerTelliS on this
1. a) Name (LAST1
ALAIN
(FIRST:)
1.b) Other Berne (a).11 env that you were ever licensed under: NOT APPLICABLE
SAME AS ABOVE
2. a) Address (Mailing):
SAME AS ABOVE
2. c) &Wrest) (Business):
5 9 2- 3 0 00 _ Extension
D.O.
55 Government Facility
60 Plant/ComMerolal Setting
20 Partnership/Group Practice
35 Nursing Home
50 Medical Society
99 Other
10
a
a
Specialty Code:___
Percent of Practice Time:
if OS, specifr.
10.a) Are you American Specialty Board Certified? N/N) Y
Al
A
CRS
D
EM
FP
IN
NS
OP
OS
OT
PA
PE
PMR
11. a) Hospitals at which you have ourrenthr affective privilegee and other Health Care Facilities with which you are associated; Percent of Practice Time et each.
(See Table 4.)
1 0 (46
Facility Code:
Facility Code 10 8
Facility Code:
Facility Cede
Facility Code:
Facility Code:
a
Was PI rof-t.
n/ ties in tot.
-%eu
hereby certify that If requesting INACTIVE status, l will not practice medicine In Massachusetts.
Pursuant to M.G.L c415,1 will not charge to or collect from a Medloare beneficiary more than the Medicare reasonable charge for my services.
Pursuant to M.G.L c62C eacegt, I certify under the pamphlet of perjury that, to my best knowledge and belief, I have flied any Massachusetts state tax
return, and paid any Massachusetts state taxes, that era required under law. Note: This applies even if you reside outotstais or out el the country.
I hereby cergly under the penalties of perjury that all Information on this form-front and back and (PI
Signature:
a( , 'Tr
Registration No.. 6 0 4 9 1
ra MPPFTi
12. 41) Other States where you are now Awned to practice (Abbreviate):
QU
ACTIVE XX
INACTIVE
If ACT1gE, antes, questIons 14. a) through c).
If !NAME, answer question 14. lgonly.
14.a) I have completed my C.M.E. requirements in the two years ending on the renewal date as follows: (Fill in g of hours or type of residency, or check waiver.)
4O hrs., Category I: 8 nhrs., (Risk-Management 1(1 hrs.), Residency Program In.
Category
Waiver Requested
(You must fill out a separate Waiver Form.)
14. b) My medical malpracilespeuranos Is covere4 by INSURANCE CAFIRIER
LETTER OF CREDIT . applicable, check one and identify the name,
insurer:NO) Nfig 41n
amality ML MA Institution ['suing Letter of Credit.
AttemaUvely, inane as follows; I am registering with ACTIVE status, butt am not covered by medical malpractice Insurance because I sat (Check one)
NOT INVOLVED IN DIRECT/INDIRECT PATIENT CARE
OTHERWISE EXEMPTED_ (State how)
14. c) Percent of Practice Time In Massachusette 10 0 %
Questions 15 through 17 refer to the gut four man, only. Check either YES or NO (not N/A)to echquestion, Protects Malls on Form 15k attached.
Itt .112
15.Has any pending or new medical malpractice claim been made against you (whether or not a lawsuit was filed in relation to the claim)?
18. Have you been a defendant in any pending or new criminal proceeding other than a minor traffic offense?
17.Are any kennel disciplinary oharges pending or has any disciplinary action (as defined by Board regulations-See Instructions) been taken
against you by any governmental authority, hospital or other health care facility, or profeseional medical association (International,
national, mate or kap
If you answered "YES" to question 15,15, or 17 provide details on Form 15A, attached.
itshttOfrOrtt Ain ** I Ei ..**.Int Sing** 0.1.1,11********.**-ltiSlr****In.A.M.*Ir
Questions le through 24 refer to the 1211120055ga only. Check either YES or NO (not N/A)to poohquestion. Provide details in the next semion.
18.Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked, denied restricted, surrendered, or
have you been called before or been warned by this state or any othsr jurisdiction Including a federal agenoy?
19.Have you withdrawn an application fora medical Boonse or been denied a medical license for any reason?
20. Have you had any mental illness which his impaired your ability to practice medicine or to function as a student of medicine?
21. Have you had an organic Ilinms which has Impaired your ability to practice medicine or to function as a student of medicine?
22. Are you now, or have you bean In the past, dependent upon alcohol or drugs?
23. Have you, for any reason, lost American Specialty Board Codification?
24. Have you been denied recertification by one or more specialty boards? DIVES, list Bat(s):
yep
COMMONWEALTH OF MASSACHUSETTS
BOARD OF REGISTRATION IN MEDICINE
SUPPLEMENT TO APPLICATION FOR
AMERICAN SPECIALTY BOARD
CA
NAME:
PERMANENT ADDRESS:
MP 8 L a_
ALAI
HOSPITAL
ADDRESS:
C44-- L
( e_
LOCAL MAIUNG:
ADDRESS IN (MA);
6 a /4. Ai
Certificate Category?
YOU ARE REQUIRED TO COMPLETE THE QUESTIONS BELOW.
1. Has any medical malpractice claim ever been made against you in the last ten years (whether or not a lawsuit
was filed In relation to the claim)?
2. Have you ever been denied the right to participate or enroll in any system whereby a third party pays all or
part of a patient's bill?
3. Have you ever applied for licensure or to sit for an examination or taken an examination, under a different name?
4. Have you ever been denied the privileges of taking or finishing an examination or been accused of cheating and/or
improper conduct during an examination since your matriculation In college?
5. Have you ever failed any of the following examinations: the FLEX examination, any state Board examination, or tailed Part III of the
National Boards or felled to gain certification from the National Board of Medical Examiners?
6. Have you ever felled a foreign licensing or certification examination?
T. Have you ever felled an AMNION% Specialty Board examination?
8. Have you ever been denied a medical license, whether full, limited or temporary, for any reason?
9. Have you ever had staff privileges, employment or appointment In a hospital or other health care institution
denied, suspended or revoked, or resigned from a medical staff in lieu of disciplinary action?
10. Are any formal disciplinary charges pending or has any disciplinary action been taken against you In the
last ten years by any governmental authority, by any hospital or health care facility, or by any professional
medical association (International, national, state or local)?
11. Have you ever voluntarily surrendered a license to practice medicine or any Slating art? The Board's
regulations define 'disciplinary action? Please refer to 243 CMR 3.02, attached.
12. Have you ever withdrawn an application for medical licensure, hospital privileges or appointment, for any reason?
13, Have you ever, for any reason, lost American Specialty Board Certification?
14. Have you been denied required recertification by one or more specialty boards? if yes, which one(s)?
15. Have you, at any time, been a defendant In any criminal proceeding other than minor traffic offenses?
16. Has your privilege to nausea, dispense or prescribe controlled substances ever been suspended, revoked, denied,
restricted or surrendered, or have you been called before or warned by this state or any other
Jurisdiction Including a federal agency at any time?
17. Have you ever had any emotions disturbance or mental Illness which has impaired your ability to practice medicine
or to function as a student of medicine?
18. Have you ever had an organic Illness which has impaired your ability to practice medicine or to function as a
student of medicine?
19. Ate you now, or have you been In the past, dependent upon alcohol or drugs?
20. Have_you ever held a license in Massachusetts or any other state or country? If yes, list other jurisdictions,
TT -1%2-
U 1)0
NOTE ON QUESTIONS 17.19: The harm that befalls physicians and patients alike when impairment goes undetected and untreated
by the medical profession is devastating. The Board wants impaired physicians treated in the early stages of Impairment
before Irreparable harm to the physician or patient occurs.
If you have answered 'yes" to any of the above except #20 please explain on the reverse side. Attach additional 8 I/2" x 11" sheets
if necessary.
I will read the Board's regulations, 243 CMR 1.00 through 3.00. To the best of my knowledge I meet the qualifications
for American Specialty Board Ucensure In Massachusetts.
I hereby certify under the penalty of perjury that all Information on this form (front and back) including attached sheets Is true.
SIGNATURE:
On
DATE:
YES NO
7r... /DO&
HE COMMONWEALTH OF MASSACHUSETTS
ARD OF REGISTRATION AND DISCIPLINE IN MEDICINE
Application for Endorsement Registration
(Fee S150,00 must accompany APPLICATION No currency
or personal checks)
IQ;
*176
Application #
Bs'
Fwm of Fee
Certificate #
P.'ease Pratt
Name Alain
Fos/
Date of Birth
SWORN STATEMENT
Lester CAMPBELL
Address
trivd/e
113R 2T6
Pre-Medical Education
Medical Education
University of Montreal
Years Attended
Lau
School
School
B.Sc. : 1969-72
B A. (.Univ. Mtl, 1969
iceilIS
McGill University
A t tended 1972 -
76
Place
M.D
C.M.
Dates
- Endocrinology)
none
List Specialty Boards by which you are certified. AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY
11/4. r;aJ$
Tv" PN-L t() 6,
ailnONit'EALTH OF MASSACHUSETTS
BOARD OF REGISTRATION IN MEDICINE
SUPPLEMENT TO APPLICATION FOR
FUO. 11,COSE
ADDRESS:
LOCAL MAILING
ADDRESS IN (MA):
Hospital
YES
NO
i.
2.
3.
4.
5,
6.
7.
8.
9.
10.
11.
12.
13.
14.
IS.
16.
17.
18.
NOTE ON QUESTIONS 15-171 The harm that befalls physicians and patients alike when
impairment goes undetected and untreated by the medical profession is devastating.
The Hoard wants impaired physicians treated in the early stages of impairment before
irreparable ham to the physician or patient occurs.
If you have answered "yes" to any of the above except #18 please explain on 'the
reverse side. Attach additional 8 1/2" x 11" sheets if necessary.
I will rend
the Board's regulations, 243 CPU 1.00 through 3.00. To the best of my knowledge
I meet the qualifications for Full Licensure in Massachusetts.
I hereby certify under the penalty of perjury that all information on this form
(front and back) including attached sheets is true.
SIGNATURE:
DATE:
MelAdt
198.1
11)
PART A
Birth Date:
If you want to change your current status, please check one of the following boxes to indicate your new status:
(Check only one). (See Renewal Instructions, page 3.)
Active
0 Inactive
El Retiring
2) Addresses & Contact Information. Please confirm your addresses and make changes, if necessary. You are
required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and
Business addresses CANNOT be a Post, Office Box.
Please make corrections (print)
2a) MAILING ADDRESS
9 BOSTON STREET
Mailing Address:
SUITE 9
State:
City/Town:
LYNN, MA 01904-0000
Country:
Zip:
2b) HOME ADDRESS
t
Phone:
El Check here to change this address rn:.a.
Home Address:
4) Fax Number:
Country:
Zip:
Home Telephone: (
0
Business Address:
State:
City/Town:
Zip:
Country:
Business Telephone: (
Phone: (781).592-3000
13 Check here to change this address
3) E-mail Address:
State:
City/Town:
Delete?
Additional specialties:
0
0
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AGA) Information.
(See enclosed instructions and Renewal Instructions, page 4.)
ABMS or AOA
0
Certificate/Subspecialty
Correct?
Delete?
0
0
s
0
0
0
0
0
Page 1 of 5
8a) Other states where you are now licensed to practice (Abbr.)
MN'S
a) Massachusetts:
b) Federal (DEA):
c) Federal (DEA) XS:
1360
Qv
9) What is your principal work setting? (See Renewal Instructions, page 4.)
Change to:
Principal Work Setting: Private Office
Please enter principal work setting hours per week here: I'
10) List all current health care facilities where you are affiliated or have completed the credentialing process for the
provision of patient care. (Supply the name of the health care facility from Reference Table 5 on Page 16 of the
Instruction booklet). Next to each facility, write your staff category at that facility (Admitting, Active, Courtesy,
Associate or Consulting), and the approximate number of hours of patient care that you provide at that facility.
Include any affiliations with on-line prescribing services or companies. Please provide all information for additional
facilities on a separate sheet, if necessary.
No Affiliations
Health Care Facility (See Renewal Instructions, page 4)
Delete?
Current
StallCategory
Change
# Hours
per Week
Admitting
e) , c
Union Hospital
Admitting
0
0
0
I i) Care of patients in Massachusetts (See Renewal Instructions, page 4)
Average weekly hours involved in: a) inpatient care
b) outpatient care
5 hrs/wk
30
hrs/wk
Change to: _ /
Change to:
hrs/wk
althrewk
From
eadieli95-
3 /en, 2.
Change to:
To 42 /6? / 9
?required)
Letter of Credit subject to Board approval (attach a copy)
I am registering with Active status but I am not required to have medical liability insurance because I am:
Check one:
Not involved with direct or indirect patient care in Massachusetts
Page 2 of 5
13) Do you perforth any surgery in your office? (See Renewal Instructions, page 5.)
Yes
No
In questions 14-21, the phrase "time period" refers to the following: all time from the day you signed your last
license renewal/application, to the day you sign this renewal application, inclusive. (See Renewal Instructions, page 5 );
You must check either YES or NO to each question. Provide details on Form R if you answer "YES" to any questions. Refer to
Renewal Instructions for additional information and definitions. ALL questions in this section must be answered.
YES NO
14) CLAIMS MADE
a) New: Has any medical malpractice claim been made against you during this time period, whether or
not a lawsuit was filed on that claim?
b) Pending: Are there any unresolved malpractice claims against you today, any claims that have not been
finally settled or finally adjudicated?
15) CLAIMS PAID
Has any medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been
resolved, settled, or adjudicated during this time period?
16) OTHER CIVIL LAWSUITS
Question 16 refers to claims or actions related to your competency to practice medicine or your
professional conduct in the practice of medicine.
a) New: Have there been any lawsuits, other than medical malpractice claims, been filed against you
during this time period?
b) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice
claims, during this time period?
17) CRIMINAL CHARGES
a) Have you been charged with any criminal offense during this time period?
b) Are there any criminal charges pending against you today?
c) Have any criminal offenses/charges against you been resolved during this time period?
18) Have you been charged with or disciplined for any violation of laws, rules, by-laws or standards of practice
of any governmental authority, health care facility, group practice or professional society or association?
19) Has your privilege to possess, dispense or prescribe controlled substances been suspended, revoked,
denied, restricted by, or surrendered:to any state or federal agency?
20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete
or have you been denied a medical license for any reason?
21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge or
co-payment, or placed any condition related to professional competency or conduct on your coverage, or
have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by
a medical liablility insurance carrier?
(ayes No
Inactive Status
Residency/Fellowship training
PHYSICIAN PROFILE
I have reviewed my Physician Profile at profiles.massmedboard.org and confirm that the information is accurate.
I have reviewed my Physician Profile and attached a copy of the Profile with corrections,
My status is Inactive and I do not have a Physician Profile. (See Renewal Instructions, page 10.)
CERTIFICATIONS
1)1 certify that 1 have complied with my obligations to report abuse or neglect of children pursuant to G.L. c. 119, sec. 51 A,
and I understand the punishment for failure to comply.
2) I certify that 1 have complied with my obligations to report abuse or neglect of disabled persons pursuant to G.L c 19C,
sec. 10, and I understand the punishment for failure to comply.
3)1 certify that I have complied with my obligations to report abuse, neglect or financial exploitation of elderly persons
pursuant to G.L. c.I9A, sec. 15, and 1 understand the punishment for failure to comply.
4) I certify that I have complied with my obligations to report the treatment of wounds, bums and other injuries pursuant to
G.L. c. 112, sec. 12A
5) I certify that I have complied with my obligations to report the treatment of victims of rape or sexual assault pursuant to
G.L.c. 112, sec. I 2A 1/2.
6)1 certify that I have complied with my obligations to report a physician to the Board of Medicine, pursuant to G.L. c. 112,
sec. 5F, when I ha* a reasonable basis to believe that person violated any provisions of G L c 112, sec. 5 or any Board
regulation.
7) I certify that I have complied my obligations related to charging and collecting fees from Medicare beneficiaries in
accordance with the Medicare fee schedule, and 1 understand my obligations under G.L. c.112, sec. 2.
8) I certify that I have complied with my obligations to file Massachusetts tax returns and to pay Massachusetts taxes, and I
understand that, pursuant to G.L. c. 62C, see. 49A, my license shall not be issued or renewed unless I make these
certifications under penalties of perjury.
9)1 certify that I have complied with my obligations related to the reporting of employees and contractors pursuant to G.L.
c.62E.
10)1 certify that I have complied with my obligations related to the withholding and remitting of child support pursuant to
G.L. c. 119A,
11) I certify that I have complied with my obligations to file an Incident Report with the Board when certain adverse events
occur in my private office, pursuant to G.L. c. 112 sec. 5 and 243 C.M.R. 3.00 et seq., and I understand that the Patient Care
Assessment (PCA) programs at the health care facilities where I practice report certain Major Incidents to the Board.
Under penafties of perjury, I declare that I have examined this renewal application and all its
accompanyinginstructions, forms and statements, and to the best of my knowledge and belief, the
information contained herein is true, correct, and complete. I authorize the Board of Registration in
Medicine to access any and all criminal case information on me held by the Massachusetts
Criminal History Systems Board.
Signature:
Date: Ob / 1967 0
MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING, FOR YOUR
RECORDS, FOR CREDENTIALINC AND OTHER PURPOSES.
Page 5 of 5
al
rd.org
Please review carefully the following informaatojaknoffil co pleteness. Make any corrections or
alterations as required. All questions must be answered or your renew will be delayed
1. Current Status: Active
Registration No.:60491
If you want to change your current status, please check one of the following boxes to indicate your new status:
0 Active
A) Mailing/Business Address:
3.
ALAIN LESTER CAMPBELL
9 BOSTON STREET
SUITE 9
LYNN, MA 01904-0000
Mailing Address:
City/Town:
Zip:
State:
Country:
B) Home Address:
Business Address:
City/Town:
Zip:
Country:
Business Telephone: (/ )
Business Phone:
4. a) Date of Birth:
b) Sex:
M
c) SS#:
5. a) Name of Medical School:
02-
5000
Home Address:_
State:
City/Town:
Country.
Zip:
Home Telephone:
PLEASE NOTE: Only mg address can be a P.O. box. The
mailing address cannot be a P.O. Box.
Home Phone:
OBG
State:
35
10. List all current health care facilities at which you a e affiliated or have completed the credentialing process for the provision of patient
care. (Supply the codes from Table 3 and place a check mark next to those health care facilities where you have admitting privileges (AP).
No affiliations.
Next to each facility, write the approximate percentage of patient care hours that you provide in each facility).
Facility Code: 5 3 *I i'''.. (AP) _ & % Facility Code: 5-3 f 1 i---- (AP) /1E)% Facility Code:
(AP)
% Facility Code:_
Facility Code: _ _ /
(AP) ___
% Facility Code:_ _/
If 999, print name(s):
/
/
_ (Al')
(AP)
cal
eta
CR licik Pete
tt-
LICENSE NUMBER:
vra
- 3/0 2. Z
6ofqi
0 Letter of Credit
Dig (1.
Alternatively, indicate as follows: I am registering with Active status but I am not covered by medical malpractice insurance
of involved in direct/indirect patient care in Massachusetts A government employee.
because I ant Check One:
Otherwise exempt Please expl exemption:
If you are affiliated with a healthcare facility or credentialed
? (See Table 4) / 5'
What
is your principal work se
12.
for the provision of patient care yo must complete question #10 on page 1 and list your affiliations.
13. Care of patients in Massachusetts see instruction booklet).
1) Average weekly hours invo ved in: A) inpatient care
40
hrs/wk
2) What is the approximate pe centage of your patient care hours in primary care?
PART A OUESTIONS REF R ONLY TO THE PAST TWO (2) YEARS (SEE INSTRUCTIONS)
Ouestions 14 through 22 refer to the period since you sinned your last renewal application. Check either YES or NO to each
question, Provide details on Form R for all YES answers (except Question 221. Refer to instructions for additional information
and definitions. ALL questions in th s section must be answered. Do not answer NA or the form will be incomplete and delay
your renewal,
XEE
NO
14. CLAIMS MADE (New or Penditiol: Has any medical malpractice claim been made against you that has not
yet been finally settled or adjudicd, whether or not a lawsuit was filed in relation to the claim?
15.CLAP Mesolvedli Has any medical malpractice claim that has been made against you been settled,
adjudicated, or otherwise resolved, whether or not a lawsuit was filed in relation to the claim?
16. Has any lawsuit, other than a medi !malpractice suit, which is related to your competency to practice medicine,
or your professional conduct in the practice of medicine, been filed against you or been settled, adjudicated or
otherwise resolved?
17. Have you been charged with any
urinal offense?
18. Have you been charged with or di iplined for any violation of laws, rules, by-laws or standards of practice of
any governmental authority, health care facility, group practice or professional society or association?
19. Has your privilege to possess, dish e or prescribe controlled substances been suspended, revoked, denied,
restricted by, or surrendered to any to or federal agency?
20. Have you withdrawn an applicatio for a medical license or been denied a medical license for any reason?
21. Has any professional liability insur ce provider restricted, limited, terminated, imposed a surcharge or
co-payment, or placed any conditio related to professional competency or conduct on your coverage, or have
you voluntarily restricted, limited o terminated your insurance coverage in response to an inquiry by a
professional liability insurance pro er?
22. CME CERTIFICATION; Have ou completed your CME requirements preceding your renewal date?
tYes 0 No
CME Waiver. CME waiver fo must be submitted at least 30 days prior to license expiration date.
Inactive status
See Instructions for CME waiver or exemptions. Do not submit documentation of your CMEs with application.
Pursuant to G.L. c. 112, Sec 1A, I understand my obligations to report abuse or neglect of children under G.L. c. 119, Sec. 5IA
and the punishment for failure to comply.
Pursuant to G.L. c. 112, Sec. 2, I will not charge to or collect from a Medicare beneficiary more than the Medicare fee schedule
amount.
Pursuant to G.L. c. 62C, 49A, I certify that I have complied with all laws of the Commonwealth related to the filing of
Massachusetts state tax returns d payment of all Massachusetts state taxes; reporting of employees and contractors under
G.L. c. 62E; and withholding and remitting child support pursuant to G.L. c. 119A. (See instructions).
Ihereby certify under the penalties f per ury that all Information on this Renewal Application, Part B and Form R Is true.
Signature:
Date:
184-1 03
you MUST SIGN AND IN UDE PART B. WITH YOUR RENEWAL APPLICATION
Board Regulations require that you notify the Board, in writine. of any thane of address
560 Harrison Avenue, Suite #G-4, Boston, MA 02118 (617) 654-9810 http://www.massmedlio"ard.org
e.
API) I I
Please review carefully the following enjoy's:043%AS oncod co pleteness. Make any corrections or
alterations as required. All questions must be answered or your renew will be delayed
1. Current Status: Active
Registration No.60491
If you want to change your current status, please check one of the following boxes to indicate your new status: (Check only one)
0 Active
A) Mailing/Business Address:
ALAIN LESTER CAMPBELL
9 BOSTON STREET
SUITE 9
LYNN, MA 01904-0000
Mailing Address:
City/Town:
Zip:
State:
Country:
B) Home Address:
Business Address:
City/Town:
State:
Zip:
Country:
Business Telephone: (/) 514- 3000
Home Address:_
City/Town:
State:
Zip:
Country:
Home Telephone:
?LEASE NOTE: Only gat address can be a P.O. box. The
mailing address cannot be a P.O. Box.
Home Phone:
Business Phone:
4. a) Date of Birth:
b) Sex:
M
c) SS#:
5. a) Name of Medical School:
b
e
1976 ci greM.D.
6. Specialty Code(s) (See Table 1)
Codes)
Hours per Week in Mass. 35
OBG
10. List all current health care facilities at which you are affiliated or have completed the credentialing process for the provision of patient
care. (Supply the codes from Table 3 and place a check mark next to those health care facilities where you have admitting privileges (AP).
Next to each facility, write the approximate percentage of patient care hours that you provide in each facility). _ No affiliations.
Facility Code: 5 3 *I L--- (AP) _--. % Facility Code: 5-3 111-- (AP) /& % Facility Code:_ _ ___/
Facility Code: _ _ I__ (AP)
% Facility Code:_
/
(AP)
% Facility Code:_
/
If 999, print name(s):
(AP)
(AP)
%
%
LICENSE NUMBER:
66141/
0 Letter of Credit
11. My medical malpractice insurance is covered by [j1nsurance Carrier
Policy dates: Front 02- / 041 03 To: 02/
vitt L
3/0 2- Z
Insurer's name, (Required):
07(
Alternatively, indicate as follows: I am registering with Active status but I tun not covered by medical malpractice insurance
because I am: Check One: 0 of involved in clirect/inclirect patient care in Massachusetts 0 A government employee.
0 Otherwise exempt Please exp in exemption:
If you are affiliated with a healthcare facility or credentialed
12. What is your principal work setting? (See Table 4) / 5for the provision of patient care you must complete question #10 on page 1 and list your affiliations.
13. Care of patients in Massachusetts ee instruction booklet).
5 hrs/wk B) outpatient care
1) Average weekly hours invo ved in: A) inpatient care
ntage of your patient care hours in primary care? 6- %
2) What is the approximate
at'
hrs/wk
PART A QUESTIONS REF R ONLY TO THE PAST TWO (21 TEARS (SEE INSTRUCTIONSI
Questions 14 through 22 refer to theI)erlod since you signed vour last renewal application. Check either YES or NO to each
Question. Provide details on Form R for all YES wirers (except Question 22). Refer to instructions for additional information
and definitions. ALL Questions in th s section must be answered. Do not answer NA or the form will be incomplete and delay
your renewal,
YES NO
14. CLAIMS MADE (New or Pendinel: Has any medical malpractice claim been made against you that has not
yet been finally settled or adjudica d, whether or not a lawsuit was filed in relation to the claim?
15. CLAIMS (Resolved): Has any edical malpractice claim that has been made against you been settled,
adjudicated, or otherwise resolved, whether or not a lawsuit was filed in relation to the claim?
16. Has any lawsuit, other than a medicat malpractice suit, which is related to your competency to practice medicine,
or your professional conduct in the practice of medicine, been filed against you or been settled, adjudicated or
otherwise resolved?
17. Have you been charged with any iminal offense?
18. Have you been charged with or d. iplined for any violation of laws, rules, by-laws or standards of practice of
any governmental authority, health care facility, group practice or professional society or association?
19. Has your privilege to possess, disp sue or prescribe controlled substances been suspended, revoked, denied,
restricted by, or surrendered to any state or federal agency?
20. Have you withdrawn an application for a medical license or been denied a medical license for any reason?
21. Has any professional liability insure ce provider restricted, limited, terminated, imposed a surcharge or
co-payment, or placed any conditio: related to professional competency or conduct on your coverage, or have
you voluntarily restricted, limited o terminated your insurance coverage in response to an inquiry by a
professional liability insurance pro "der?
22. CMC CERTIFICATION; Have ou completed your CME requirements preceding your renewal date? &Yes 0 No
0 CME Waiver. CME waiver foi must be submitted at least 30 days prior to license expiration date.
0 Residency/Fellowship training (See instructions).
CME EXEMPTION: Check ong 0 Inactive status
See Instructions for CME waiver or exemptions. Do not submit documentation of your CMEs with application.
Pursuant to G.L. c. 112, Sec IA, I understand my obligations to report abuse or neglect of children under G.L. c. 119, Sec. 51A
and the punishment for failure comply.
Pursuant to G.L. c. 112, Sec. 2, 1 will not charge to or collect from a Medicare beneficiary more than the Medicare fee schedule
amount.
Pursuant to G.L. c. 62C, 49A, I certify that I have complied with all laws of the Commonwealth related to the filing of
Massachusetts state tax returns
payment of all Massachusetts state taxes; reporting of employees and contractors under
G.L. c. 62E; and withholding and remitting child support pursuant to G.L. c. 119A. (See instructions).
I hereby certify under the penalties f per ury that all Information on this Renewal Application, Part B and Form R is true.
Signature:
Date: 41 te / 81" / 03
YOU MUST SIGN AND IN UDE PART B. WITH YOUR RENEWAL APPLICATION
Board Regulations reouire that you notify the Board, in writing, of any change of address
MAKE A COPY OF YOU'li APPLICATION AND ALL ATTACHMENTS BEFORE MAILING.
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M D
Home Address:
Business Address:
3) Email Address:
4) Fax Number: (781) 438-9601
5) Specialties
Obstetrics and Gynecology
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Information
ABMS/AOA Board Name
ABMS
Obstetrics & Gynecology
Certification
Obstetrics and Gynecology
Subspecialty
Federal IDEA)
Federal (DEA) XS
Page 1 of 5
Location
None Reported
Date: 4/26/2011
Time: 11:17 AM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
Policy Type
Occurrence Policy
Page 2 of 5
Date: 4/26/2011
Time: 11:17 AM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
22) Have you completed all CME requirements (100 hours of CME of which 10 hours must be in risk
management. Requirement: 40 hours credit in Category 1 and 60 hours in Category 2) for this
renewal period? (If you are in an approved Residency/ Fellowship program, or if your are
renewing your license for the first time, please answer Yes)
Page 3 of 5
Date: 4/26/2011
Yes
Time: 11:17 AM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
23) Do you have a medical condition that interferes in any way or limits your ability to practice
medicine?
24) Have you used any chemical substance(s) which in any way interferes with your ability to
practice medicine?
Page 4 of 5
Date: 4/26/2011
Time: 11:17 AM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M D
pg
I have reviewed the above statements and certify that 1 understand my requirement to comply with
the responsibilities and obligations of each and agree to do so.
IN
Under penalties of perjury, I declare that I have examined this renewal application and all of its
accompanying instructions, forms and statements, and to the best of my knowledge and belief, I
certify that the information contained herein is true, accurate, and complete.
Page 5 of 5
Date: 4/26/2011
lime: 11:17 AM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M.D.
Home Address:
Business Address:
3) Email Address:
4) Fax Number: (781) 438-9601
5) Specialties
Obstetrics and Gynecology
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Information
ABMS/AOA Board Name
ABMS
Obstetrics & Gynecology
7) Drug License Numbers
Massarhimatts
Certification
Obstetrics and Gynecology
Federal IDEAI
Subspecialty
Federal (DEA) XS
Page 1 of 5
Location
None Reported
Date: 4/30/2013
liras: 12:37 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
Page 2 of 5
Date: 4/30/2013
Time: 12:37 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
20) Have you withdrawn an application for a medical license, allowed a license application to
become obsolete or have you been denied a medical license for any reason?
21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge
or co-payment, or placed any condition related to professional competency or conduct on your
coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in
response to an inquiry by a medical liability insurance carrier?
22) Have you completed all CPD requirements (100 hours of CPD of which 10 hours must be in risk
management. Requirement: 40 hours credit in Category 1 and 60 hours in Category 2) for this
renewal period? (If you are in an approved Residency/ Fellowship program, or if your are
renewing your license for the first time, please answer Yes)
Page 3 of 5
Date: 4/30/2013
Yes
Time. 12:37 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M D
23) Do you have a medical condition that interferes in any way or limits your ability to practice
medicine?
Lymphoma Dec.2011, at Mass MGH Chemo.Dec Jun2012;complications; insurance not renewed per
243 CMR 2.07 (16)(d)not engaged in practice;have tail; will re-activate when stable
24) Have you used any chemical substance(s) which in any way interferes with your ability to
practice medicine?
Page 4 of 5
Date: 4/30/2013
Time: 12:37 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M D
Online profile:
I have reviewed my Physician Profile and confirm that the information is accurate.
1) I understand and agree to comply with my obligations to report abuse or neglect of children pursuant to
M.G.L. c. 119 sec. 51A and I understand the punishment for failure to comply.
2) I understand and agree to comply with my obligations to report abuse or neglect of disabled persons
pursuant to M.G.L. c. 19C sec. 10 and I understand the punishment for failure to comply.
3) I understand and agree to comply with my obligations to report abuse, neglect or Financial exploitation of
elderly persons pursuant to M.G.L. c. 19A sec. 15 and I understand the punishment for failure to comply.
4) I understand and agree to comply with my obligations to report the treatment of wounds, burns and other
injuries pursuant to M.G.L. c. 112 sec. 12A and I understand the punishment for failure to comply.
5) I understand and agree to comply with my obligations to report the treatment of victims of rape or sexual
assault pursuant to M.G.L. c. 112 sec. 12A 1/2 and I understand the punishment for failure to comply.
6) I understand and agree to comply with my obligations to report a physician to the Board of Medicine
pursuant to M.G.L. c. 112 sec. 5F, when i have a reasonable basis to believe that a person violated any
provisions of M.G.L. c. 112 sec. 5 or any Board regulation.
7) I understand and agree to comply with my obligations related to charging and collecting fees from Medicare
beneficiaries in accordance with the Medicare fee schedule, pursuant to M.G.L. c. 112 sec. 2.
8) I understand and have complied with my obligations to file Massachusetts tax returns and to pay
Massachusetts taxes and I understand that, pursuant to M.G.L. c. 62C sec. 49A, my license shall not be
issued or renewed unless I make this certification under penalties of perjury.
9) I understand and agree to comply with my obligations related to the reporting of the wages of employees
and contractors pursuant to M.G.L. c. 62E Sec. 2.
10)1 understand and agree to comply with my obligations related to the withholding and remitting of child
support payments pursuant to M.G.L. c. 119A.
11)1 understand and agree to comply with my obligations to file an Incident Report with the Board when certain
adverse events occur in my private office, pursuant to M.G.L c. 112 sec. 5 and 243 CMR 3.00 et seq. and I
understand that the Patient Care Assessment (PCA) programs at the health care facilities where I practice
report certain Major Incidents to the Board.
12)1 understand and agree to comply with my obligations to disclose ownership interest in any partnership,
corporation, firm or other legal entity to which I have referred a patient for physical therapy services,
pursuant to M.G.L c. 112 sec. 12AA.
13)1 am aware of my obligations and responsibilities under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), including the requirement that I obtain and provide to the Board a National Provider
Identifier (NPI) number.
14)1 understand and am in compliance with HIPAA and all other federal and state obligations placed upon me
as a physician.
15)1 understand that as an applicant for a license renewal to practice medicine a criminal record check may be
conducted for conviction and pending criminal case information only from the Criminal History Systems
Board and that it will not necessarily disqualify me.
El
I have reviewed the above statements and certify that I understand my requirement to comply with
the responsibilities and obligations of each and agree to do so.
El
Under penalties of perjury, I declare that I have examined this renewal application and all of its
accompanying instructions, forms and statements, and to the best of my knowledge and belief, I
certify that the information contained herein is true, accurate, and complete.
Page 5 of 5
Date: 4/30/2013
Time: 12:37 PM
MEDEODEI
O I have personally applied for an NPI. (You must provide your NPI number to the Board when received.)
O 1 have applied for an NPI using a third party (enter name)
21 By checking this option and signing the bottom of this page, 1 hereby authorize the Board to apply for an NPI on my behalf.
O As an inactive physician, I do not wish to obtain an NPI.
JIIPAA TAXONOMY CODES
Please provide the HIPAA taxonomy (specialty) codes (refer to enclosed Taxonomy Code List). In addition to providing the taxonomy
code, please indicate your specialty in the space provided (Taxonomy Description). The primary provider taxonomy code is required if you
authorize BORIM to apply for an NPI on your behalf.
Taxonomy (Specialty) Code
Primary Provider Taxonomy:
Provider Taxonomy:
Provider Taxonomy:
0 bg rf-Tret es 4
a',ovtcotta y
0 Female
Gender: 11t Male
Penalties for Falsifying Information on the National Provider Identifier Application
18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of
the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false,
fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false,
fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years.
Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain
derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.
Authorization for NPI Dissemination
Check one box: ig I authorize 0 I do not authorize the Board of Registration in Medicine to provide my NW number to any
authorized hospital, health plan, or health organization.
Please sign and date to confirm th t all of the information on this form is true and accurate.
Signature:
Date: 0 2
/ /1 / gab
F. rto, ra M
LLD -1.
nl F
ay
1:::7 LI::
01/25/2007
Dear Colleague:
As you may know, the Health Insurance Portability and Accountability Act (HIPAA) mandates the use of the
National Practitioner Identifier (NH), a unique identifier for health care providers. The NPI program is overseen by
the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services.
Under the final HIPAA NPI rule, all individual and organization covered providers will be required to obtain a NPI
by May 23. 2007. Without this number, you may be ineligible for reimbursement from federally-funded benefits
programs. As a condition for renewal of your license, you must complete the NPI form on the attached page.
The Massachusetts Board of Registration in Medicine (Board) is assisting physicians to obtain their NPI numbers.
In addition to providing this service for physicians, the Board is the designated repository for electronic storage and
dissemination of the NPI number. By having your NPI in this central repository, we hope to reduce the amount of
administrative duplication in your office.
Please follow the instructions on the NPI form on the back of this letter. If you already have a NPI number, you
must enter it in the space provided. If you have not yet submitted an application for a NPI number, you may request
that the Board apply for the NPI number on your behalf, or you must indicate that it is being requested by another
entity. You must check one of the boxes regarding NPI and you must sign and date the form to authorize the Board
to provide the NPI number to authorized entities, although this is not required. Should you need any assistance in
completing the NPI form, please contact the NPI coordinator at (617) 654-9810.
I would also like to take this opportunity to thank you for your continued service to the citizens of the
Commonwealth.
Sincerely,
PART A
1) Current Status: Active
Birth Date
If you want to change your current status, please check one of the following boxes to indicate your new status:
Check only one: (See Renewal Instructions, page 3.)
Retiring
Active
Inactive
2) Addresses & Contact Information. Please confirm your addresses and make changes, if necessary. You are
required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and
Business addresses CANNOT be a Post Office Box.
Please make corrections (print)
2a) MAILING ADDRESS
9 Boston Street
Suite 9
Lynn, MA 01904-0000
Mailing Address:
APR I 0 2007
City/Town:
Zip:
State:
Country:
Home Address:
City/Town:
Zip:
State:
Country:
Home Telephone:(
Phone:
Business Address:
City/Town:
Zip:
State:
Country:
Business Telephone: (
Phone: (781)592-3000
781-592-9625
Delete?
0
0
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information.
(See enclosed instructions and Renewal Instructions, page 4.)
Board Name
Certificate/Subspecialty
Delete?
ABMS or AOA
ABMS
0
0
0
Page 1 of
a) Massachusetts:
b) Federal (DEA):
UI
10) List all work sites in Massachusetts, including health care facilities (where you are credentialed), private
offices, clinics, nursing homes, etc. For the names of the health care facilities, refer to Reference Table 4 on
page 18 of the Renewal Instruction booklet. Include any affiliations with Internet-based prescribing services
or companies. Please provide all information on all work sites, attaching a separate sheet, if necessary.
List the names of all work sites in Massachusetts
(See above and description on page 4.)
Location
(City or Town)
SOLta
Aryl,/
Union Hospital
State
Delete'
AA-
frit
II
I hrs/wk
Change to
hrs/wk
18 hrs/wk
Change to:
hrs/wk
12) Medical Liability Insurance Information (See Renewal Instructions, page 5.)
Check one. Locum tenens must list policy dates. My medical liability insurance is provided through:
alnsurance Carrier (complete below)
Current Insurance Carrier: ProMutual Group
Policy dates: From 02 /C42 cfacq To ea to 7.-
Change to.
Type of Policy:
I Occurrence Policy
13) Do you perform any surgery in your Massachusetts office? (See Renewal Instructions, page 3)
If Yes, please complete Form PCA-O "Office Based Surgery" Form on page 8.
Page 2 of 9
Yes
No
In questions 14-21, the phrase "time period" refers to the following all time from the day you signed your las
license Renewal Application to the day you sign this Renewal Application. (See Renewal Instructions, page 5.)
You must check either YES or NO to each question. Provide details on Form R if you answer "YES" to any questions. Refer to
Renewal Instructions for additional information and definitions.
YES NO
14) CLAIMS MADE
UI
a) NEW: Have you received notification of a claim, whether or not a lawsuit was filed on that claim, or
has any medical malpractice claim been made against you during this time period? (see above).
b) PENDING: Are there any unresolved malpractice claims against you today, i.e., any claims that have
not been finally settled or finally adjudicated?
15) CLAIMS CLOSED
Has any medical malpractice claim against you (whether or not a lawsuit was filed on that claim) been
resolved, settled, or adjudicated during this time period?
16) OTHER CIVIL LAWSUITS
Question 16 refers to claims or actions related to your competency to practice medicine or your
professional conduct in the practice of medicine.
a) New: Have there been any claims, other than medical malpractice claims, filed against you during
this time period?
b) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice
claims, during this time period?
17) CRIMINAL CHARGES
a) Have you been charged with any criminal offense during this time period?
b) Have any criminal offenses/charges against you been resolved during this time period?
c) Are there any criminal charges pending against you today?
d) Are any Applications for Issuance of Process pending against you?
IS) INVESTIGATIONS AND DISCIPLINARY ACTIONS
a) Have you withdrawn an application to any governmental authority, health care facility, group practice,
employer or professional association?
b) Have you ever taken a leave of absence from any health care facility, group practice or employer?
c) Have you been the subject of an investigation by any governmental authority, health care facility, group
practice, employer or professional association?
d) Have you been the subject of a disciplinary action taken by any governmental authority, health care
facility, group practice. employer or professional association?
19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked,
denied, restricted by, or surrendered to any state or federal agency?
20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete
or have you been denied a medical license for any reason?
21) Has any medical liability insurance carrier restricted, limited. terminated, imposed a surcharge or
co-payment, or placed any condition related to professional competency or conduct on your coverage, or
have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by
a medical liability insurance carrier?
22) CME CERTIFICATION:
a) Have you completed your CME requirements preceding your renewal date?
is Yes
No
1:1Yes
No
A CME waiver request form must be submitted at least 30 days prior to your license expiration date.
c) If you are exempt from CME requirements, check reason for exemption. (See Renewal Instrctions, page 8.)
CM E EXEMPTION: (check one)
Page 3 of 9
Inactive Status
Residency/Fellowship training
1.1
PART C
Check One:
PHYSICIAN PROFILE
V-- I have reviewed my Physician Profile at hatp://profiles.massmedboard.ore and confirm that the information is accurate.
(Please note that if you changed or corrected your business address, business phone number, practice specialty, board
certification and/or hospital affiliations on your renewal application, your Physician Profile will also be updated.)
I have reviewed my Physician Profile and attached a copy of the Profile with corrections.
My status is Inactive and I do not have a Physician Profile. (See Renewal Instructions, page 11.)
01.
CERTIFICATIONS
1) I certify that I have complied with my obligations to report abuse or neglect of children pursuant to G.L. c. 119, sec. 51A, and I
understand the punishment for failure to comply.
2)1 certify that I have complied with my obligations to report abuse or neglect of disabled persons pursuant to G.L. c. I9C, sec. 10, and
I understand the punishment for failure to comply.
3) I certify that I have complied with my obligations to report abuse, neglect or financial exploitation of elderly persons pursuant to
G.L. c.I9A, sec. 15, and I understand the punishment for failure to comply.
4) I certify that 1 have complied with my obligations to report the treatment of wounds, bums and other injuries pursuant to G.L. c. 112,
sec. 12A.
5) I certify that I have complied with my obligations to report the treatment of victims of rape or sexual assault pursuant to G.L. c. 112,
sec. 12A 1/2.
6) I certify that I have complied with my obligations to report a physician to the Board of Medicine, pursuant to G.L. c. 112, sec. 5F,
when 1 have a reasonable basis to believe that person violated any provisions of G.L. c. 112, sec. 5 or any Board regulation.
7)1 certify that I have complied with my obligations related to charging and collecting fees from Medicare beneficiaries in accordance
with the Medicare fee schedule, and I understand my obligations under G.L. c. 112, sec. 2.
8)1 certify that I have complied with my obligations to file Massachusetts tax returns and to pay Massachusetts taxes, and I understand
that, pursuant to G.L. c. 62C, sec. 49A, my license shall not be issued or renewed unless I make these certifications under penalties of
perjury.
9) I certify that I have complied with my obligations related to the reporting of employees and contractors pursuant to G.L. 62E.
10) I certify that 1 have complied with my obligations related to the withholding and remitting of child support pursuant to G.L. c.l 19A.
II) I certify that I have complied with my obligations to file an Incident Report with the Board when certain adverse events occur in my
private office, pursuant to G.L. c. 112 sec. 5 and the Patient Care Assessment Regulations, 243 C.M.R. 3.00 et sea. I understand that
the Patient Care Assessment (PCA) programs at the health care facilities where 1 practice report certain Major Incidents to the Board.
12) I certify that I have complied with my obligations to disclose my ownership interest in any partnership. corporation, firm or other
legal entity to which I have referred a patient for physical therapy services pursuant to G.L. c. 112. sec. 12AA.
Under penalties of perjury, I declare that I have examined this renewal application and all its accompanying
instructions, forms and statements, and to the best of my knowledge and belief the information contained
herein is true, correct, and complete. As an applicant for renewal of a license to practice medicine, I
understand that a criminal record check may be conducted for conviction and pending criminal case
information front the Criminal History Systems Board only and that it will not necessarily disqualify me from
licensure.
Signature:
Date: ,0
/1.3 /
6, 3
MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. YOU MUST RETAIN A
COPY OF YOUR APPLICATION FOR YOUR RECORDS, FOR CREDENTIALING AND FOR OTHER PURPOSES.
Page 5 of 9
Dear Colleague:
As you may know, the Health Insurance Portability and Accountability Act (HIPAA) mandates the
use of the National Practitioner Identifier (NPI), a unique identifier for health care providers. The
NPI program is overseen by the Centers for Medicare and Medicaid Services (CMS) under the
Department of Health and Human Services. Under the final HIPAA NPI rule, all individual and
organization covered providers will be required to obtain a NPI by May 23, 2007. Without this
number, you may be ineligible for reimbursement from federally-funded benefits programs. As a
condition for renewal of your license, you must complete the NPI form on the attached page.
The Massachusetts Board of Registration in Medicine (Board) is assisting physicians to obtain their
NPI numbers. In addition to providing this service for physicians, the Board is the designated
repository for electronic storage and dissemination of the NPI number. By having your NPI in this
central repository, we hope to reduce the amount of administrative duplication in your office.
Please follow the instructions on the NPI form. If you already have a NPI number, you may enter it in
the space provided. If you have not yet submitted an application for a NPI number, you may request
that the Board apply for the NPI number on your behalf You must sign and date the NPI form to
authorize the Board to provide the NPI to authorized entities. Should you need any assistance in
completing the NPI form, please contact the NP1 coordinator at (617) 654-9810.
I would also like to take this opportunity to thank you for your continued service to the citizens of the
Commonwealth.
Sincerely,
Page 6 of 9
The primary purpose of the NPI is to uniquely identify health care providers as "health care providers" in HIPAA standard transactions:--I
The NP1 will replace all other identifiers assigned to health care providers, such as those assigned by health plans, government programs.
and health care purchasers for purposes of conducting these business transactions.
Under the final HIPAA NP1 Rule, all individual and organization covered providers will be required to obtain an NPI by May 23, 2007.
In order for your license to be renewed you must take one of the following actions:
Option 1: Supply the Board of Registration in Medicine with your valid NPI. You can apply for an NPI directly by using the NPPES 64&b
site at www.NPPES.cms.hhs.gov.
Option 2: Certify you have personally applied for your NPI and you have not received it yet. Once you have received your NPI Number,
you must notify the Board. Please complete the NPI form at the Board's web site at www.massmedboard.org.
Option 3: Certify another authorized institution has applied for an NPI on your behalf and you have not received it yet (supply
institution's name). Once you have received your NPI Number, you must notify the Board by completing the NPI form at the
Board's website (see Option 2).
Option 4: Authorize the Board of Registration in Medicine to apply for an NPI on your behalf.
Option 5: If your license status is INACTIVE, you may elect not to obtain an NPI number.
Check the appropriate box below, supply appropriate information, and sign the bottom of the page.
E)D)
16.10
O I have personally applied for an NPI. (You must provide your NPI number to the Board when received.)
O I have applied for an NPI using a third party (enter name):
By checking this option and signing the bottom of this page, I hereby authorize the Board to apply for an NPI on my behalf.
Please provide the HIPAA taxonomy (specialty) codes (refer to Renewal Instructions, page 21 for more information). In addition to
providing the taxonomy code, please indicate your specialty in the space provided (Taxonomy Description). The primary provider
taxonomy code is required if you authorize BORIM to apply for an NPI on your behalf.
Taxonomy (Specialty) Code
Primary Provider Taxonomy:
Provider Taxonomy:
Provider Taxonomy:
01.9J
01:c1
)00 dx
00 I 0000 I
110 I noun I
dencoces- cyiacetiti
CANA*
0 Female
17---
PART A
Birth Date:
Renewal Due Date: 03/31/2009
1) Current Status: Active
If you want to change your current status, please check one of the following boxes to indicate your new status:
Check only one: (See Renewal Instructions, page 3.)
0 Do not wish to renew
0 Inactive
0 Retiring
0 Active
2) Addresses & Contact Information. Please confirm your addresses and make changes, if necessary. You are
required to notify the Board of Registration in Medicine within 30 days of any change of address. Home and
Business addresses CANNOT be a Post Office Box.
Please make corrections (print)
2a) MAILING ADDRESS
9 Boston Street
Mailing Address:
Suite 9
State:
City/Town:
Lyon, MA 01904-0000
County:
Zip:
Check here to change this address
2b) HOME ADDRESS
Home Address:
State:
City/Town:
Country:
Zip:
Phone:
El Check here to change this fres:
2c) BUSINESS ADDRESS
9 Boston Street
Suite 9
Lynn, MA 01904-0000
APR
Home Telephone: (
22
2009
Business Address:
Qoard of Registration
In MeclIgine
State:
City/Town:
Country:
Business Telephone: (
Phone: (781)592-3000
Check here to change this address
3) E-mail Address:
4) Fax Number:
781-592-9625
Delete?
0
0
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information.
(See enclosed instructions and Renewal instructions, page 4.)
List Certifying Board(s) below:
Board Name
Obstetrics & Gynecology
Delete?
0
0
0
0
Page 1 of 7
Co
co
(.0
Corrections:
AW
9) States where you were previously licensed
10) List all work sites in Massachusetts, including health care facilities (where you are credentialed), private
offices, clinics, nursing homes, etc. For the names of the health care facilities, refer to Reference Table 4 on
page 18 of the Renewal Instruction booklet. Include any affiliations with Internet-based prescribing services
or companies. Please provide all information on all work sites, attaching a separate sheet, if necessary.
Location
(City or Town)
State
Delete?
Union Hospital
.
0
0
iii
I hrs/wk
18 hrs/wk
hrs/wk
Change to
Change to: /9' hrs/wk
12) Medical Liability Insurance Information (See Renewal Instructions, page 5.)
Check one. Locum tenens must list policy dates. My medical liability insurance is provided through:
0 Insurance Carrier (complete below)
Current Insurance Carrier: ProMutual Group
Policy dates: From ita. / Oft
e9
Change to:
To 02 I 011 / 0
Occurrence Policy
Type of Policy: 0 Claims made with tail coverage
(Enclose a copy of the certificate of insurance or the face sheet)
Letter of Credit subject to Board approval (Attach a copy.)
0 1am registering with Active status but I am not required to have medical liability insurance because I am:
Check one:
13) Do you perform any surgery in your Massachusetts office? (See Renewal Instructions, page 5.)
If Yes, please complete Form PCA-0 "Office Based Surgery" Form on page 8.
Page 2 of 7
Yes
No
In questions 14-21, the phrase "time period" refers to the following all time from the day you signed your last
license Renewal Application to the day you sign this Renewal Application. (See Renewal Instructions, page 5.)
You must check either YES or NO to each question. Provide details on Form It if you answer "YES" to any questions. Refer to
tr
19) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked,
denied, restricted by, or surrendered to any state or federal agency?
20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete
or have you been denied a medical license for any reason?
21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge or
co-payment, or placed any condition related to professional competency or conduct on your coverage, or
nse to an inquiry by
have you voluntarily restricted, limited or terminated your insurance coverage in i
a medical liability insurance carrier?
Yes
No
Yes
No
A CME waiver request form must be submitted at least 30 days prior to your license expiration date.
c) If you are exempt from CME requirements, check reason for exemption. (See Renewal Instructions, page 8)
CME EXEMPTION: (check one) . Inactive Status
Page 3 of 7
Residency/Fellowship training
PART C
N
2
2
v
1) I certify that I have complied with my obligations to report abuse or neglect of children pursuant to G.L. c. 119, sec. 5I A, and I ...,i
CERTIFICATIONS
PHYSICIAN PROFILE
ig
I have reviewed my Physician Profile at http://profiles.rnassmedboard.ora and confirm that the information is accurate.
(Please note that if you changed or corrected your business address, business phone number, practice specialty, board
certification and/or hospital affiliations on your renewal application, your Physician Profile will also be updated.)
I have reviewed my Physician Profile and attached a copy of the Profile with corrections.
My status is Inactive and I do not have a Physician Profile. (See Renewal Instructions, page .)
Under penalties of perjury, I declare that I have examined this renewal application and all its accompanying
instructions, forms and statements, and to the best of my knowledge and belief the information contained
herein is true, correct, and complete. As an applicant for renewal of a license to practice medicine, I
understand that a criminal record check may be conducted for conviction and pending criminal case
information from the Criminal History Systems Board only and that it will not necessarily disqualify me from
licensure.
Signature:
Date: 03
/r/
4,, 7
MAKE A COPY OF YOUR APPL CATION AND ALL ATTACHMENTS BEFORE MAILING. YOU MUST RETAIN A
COPY OF YOUR APPLICATION FOR YOUR RECORDS, FOR CREDENTIALING AND FOR OTHER PURPOSES.
Page 5 of 7
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
Home Address:
Business Address:
3) Email Address:
4) Fax Number: (781) 438-9601
5) Specialties
Obstetrics and Gynecology
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Information
Subspecialty
Certification
ABMS/A0A Board Name
None Reported
7) Drug License Numbers
Massachusetts
Federal (DEA) XS
Federal (DEA)
Location
Date: 4/28/2015
lime: 5:54 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
Page 2 of 6
Date: 4/28/2015
Time: 5:54 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
20) Have you withdrawn an application for a medical license, allowed a license application to
become obsolete or have you been denied a medical license for any reason?
21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge
or co-payment, or placed any condition related to professional competency or conduct on your
coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in
response to an inquiry by a medical liability insurance carrier?
22) Have you completed all of the CPD requirements for this renewal cycle? If you are renewing
your license for the first time or participating in postgraduate training, please answer Yes.
Page 3 of 6
Date: 4/28/2015
Yes
Time: 5:54 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M.O.
23) Do you have a medical condition that interferes in any way or limits your ability to practice
medicine?
24) Have you used any chemical substance(s) which in any way interferes with your ability to
practice medicine?
Page 4 of 6
Date: 4/28/2015
lime: 5:54 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
Physician Name: Alain Lester Campbell, M D
Page 5 of 6
Date: 4/28/2015
lime: 5:54 PM
Commonwealth of Massachusetts
Board of Registration in Medicine
Physician Renewal Application
License No.: 60491
I have reviewed the above statements and certify that I understand my requirement to comply with
the responsibilities and obligations of each and agree to do so.
El
Under penalties of perjury, I declare that I have examined this renewal application and all of its
accompanying instructions, forms and statements, and to the best of my knowledge and belief, I
certify that the information contained herein is true, accurate, and complete.
Page 6 of 6
Date: 4/28/2015
Time: 5:54 PM
Commonwealth of Massachusetts
November 8, 2002
REDACTED COPY
Main L Campbell. MD
9 Boston Street - Suite 9
Lynn, Massachusetts 01904
Re:
Docket No: 02-179
Dear Dr. Campbell:
The Complaint Committee of the Board met on November 6, 2002 and discussed the
above-mentioned complaint.
The Committee also determined that no further action was warranted and the complaint
was closed. If you have any questions, please call Patricia Carlson of the Clinical Care Unit at
(617) 654-9891, or write to her at the address above.
RT/tcg
Commonwealth of Massachusetts
November 8, 2002
Re:
13AOCU1SHAREM ETTFR8101141:141,44NT
CO
0
'
6
July 18, 2002
Ms Luz A. Carrion
Paralegal, Clinical Care Unit
Board of Registration in Medicine
Boston, MA
Dear Ms Carrion:
The medical record of
is enclosed. You asked for ultrasound films, so
I suppose you wonder why there is a discrepancy between my results and the ultra-sound
performed elsewhere.
The following comments expressed in quotes come from Williams Obstetrics, the
classical textbook of Obstetrics (Williams Obstetrics, Norwalk, CT, Appleton & Lange)
1- Many Ob/G9n and Hospitals use different tables for fetal measurements, hence
different results: "As emphasized by linty (1991), deciding which table(s) to use
can be difficult".
2- The choice of the percentile will influence results: "For example, a biparietal
diameter of 40mm could represent a fetus of 14 weeks (5th percentile) or 20 weeks
(95th percentile) as compared with 17 weeks when the 50th percentile is used."
Most clinicians (but not all) will use the 50th percentile.
3- I have had other cases in the office where my ultrasound gave the same results as
an ultrasound performed elsewhere.
4- Even with the same table, there is a variation among readers: "Different fetal
dimensions have different reliability and ease of measurement at different
gestational ages."
5- The exam and ultrasound were made to assess the feasibility of an abortion, as
expressed earlier, not to determine if there were twins, triplets, etc.. The
diagnosis of twins is often missed, even with ultrasound: "Most contemporary
reports on twin gestations where selective (based on indications) ultrasound
examinations were performed indicate that about 80 percent of twins are
diagnosed before labor using this approach (Andrews and colleagues. 1991;
Kovacs and co-workers, 1989). ICemppaineu and co-workers (1990) diagnosed
three fourths of twins by 21 weeks in over 4600 Helsinki women receiving
clinically indicated ultrasound examinations. ... The identification of pregnancy
complicated by multiple fetuses is missed not so much because it is unusually
difficult but because the examiner fails to keep the possibility in mind." So a
fairly large number of twins are missed on clinical grounds.
6- The patient left a Lynn address, so I referred her to an Ob/Gyn in Lynn, Dr.
, 225 Boston St. (my address is 9 Boston St.). The office was closed when I
k)
to
10
called but I left a message for her to be seen the next week for =dimity of cart I
understand she now gives a New Hampshire address.
7- The subsection "diagnosis of multiple fetuses" in the chapter "Multiple
pregnancy" starts in Williams with the following comments: "It is unfortunate
that the diagnosis of twins has frequently not been made until late in pregnancy,
often as late as the time of labor and delivery."
8- "Before the third trimester, it is difficult to diagnose twins by palpation of fetal
parts. It is apparent in Figure 39-9 that even late in pregnancy it may not always
be possible to identify twins by transabdominal palpation, especially if one twin
overlies the other, ...
9- "In the case of a woman that appears large for gestational age, the following
possibilities are considered: (1) multiple fetuses, (2) elevation of the uterus by a
distended bladder, (3) inaccurate menstrual history, (4)hydrainnios, (5)
hydatidiform mole, (6) uterine myomas or adenomyosis, (7) a closely attached
adnexal mass, and (8) fetal macrosomia late in pregnancy." Again, my exam was
to determine the safety Of performing an abortion in the office, not to determine
would have investigated her the next
the many causes mentioned above. Dr.
week by a complete obstetrical exam of a regular 013 patient and the ordering of a
complete and thorough detailed ultrasound exam in the hospital.
I believe that I have illustrated my point. I know many surgeons who have removed a
normal appendix on a pathology exam but they acted with good faith and do not have
to justify themselves at various units of the Board of Registration in Medicine. As
well, patients have to pay a fee for the medical service rendered.
I do have medical expenses to run my office and it is perfectly legal to charge patients
for a medical visit and physical exam including ultrasound for evaluation of the
feasibility of a safe abortion in the office. This is a standard fee in abortion clinics in
this state. This case is a medical act like any medical act. There will be many months
before we know how many.weeks she approximately was at the time of the visit but
still here, as we are dealing with clinical medicine, there will be a range of weeks. We
are dealing with clinical medicine, not mathematics. The BPD (biparietal diameter)
found by the other physician is not the gold standard of medicine and I am happy that
be/she found the patient is having twins on a complete antenatal ultrasound evaluation
for regular obstetrical care.
The report of the ultrasound (U/S) is enclosed in the medical notes, page 8 of the
chart of the patient, as is done at Repro abortion clinics and Women care clinic,
across Massachusetts. Fundal size was 25 cm, corresponding to a normal clinical
pregnancy of 24-26 weeks. BPI) was estimated at 53-54mm, corresponding to a
gestation of 22 weeks. Femur could not be assessed accurately as the fetus was
moving too much, so a questionable 44ntm, which would be 24 wet Again,
discrepancies were not analyzed as it was not a case for the office. As you will note,
there is no place in the chart for placental location as the U/S is done simply to
complement a clinical exam; if appropriate, write placental location in the chart
Many physicians known to me do not even use ultrasound to perform abortions.
CO
ri
U)
6
I hope the patient can understand those limitations in the practice of medicine.
Thank you and sincerely yours,
0
10
0
0
COMPLAINT FORM
Please type or print clearly, and provide all of the information requested
O Mrs. Your Find Name
Your Last Name
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Ends.
amt,_
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BusinersiDaythne Phone
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contact the Division of Registration at (817)727-7498. or 298 Causeway St., Boston. MA 0211(1
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CI
iti
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Date of Birth: _
L._
Address: _
I HEREBY AUTHORIZE ANY AND ALL HEALTHCARE PROVIDERS OR INSTITUTIONS TO RELEASE
ANY AND ALL OF MY MEDICAL RECORDS TO, AND TO DISCUSS MY MEDICAL CARE WITH, THE
MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE.
Signature of Patient:
(Or Legal Representative)
_ Date: 3/1
AA.
Date: V7/0 a
Pleas Mat die cdoies and address of all healthcare raiders aid testkadons dot provided treettaent whirl on able to this carpel%
If you are not the patient, what is your relationship to the paged?
0 Friend, 0 Attorney, 0 Other
0 Spouse, a Parent, 0 Child. 0 Other Relative
Has this physician provided treatment in the past? (Do not count the treatment In this complaint.)
0 Yes. No
Is this physidan flue penal you (or patient) usually see when you (or patient) are up
D Wall No
How losig,htve you (or patient) been under this physician's care?
10 1 to 30 days, CI I to 12 months, 0 I to 2 years, 02 to 4 years, 0 4 to 8 years, 0 3 years or more
What form of payment was made? Check as many as apply.
a, . 0 Medlajd, 0 Medicare, 0 Champus
0 Commercial Insurance, 0 gad&
O Workers' Compensation. 0 Self, 13 OthertatiAlq\dth to40r'e_ret)
Are you (og patient) expected to pay a portion of this bill odor pocket?
II Yes, 0 No
Has the physicien Austad the bill In any way, for sample, was the fee or copayroat reduced or waived?
0 Yes. No
Is the fee ty copaymeat In dispute?
ID Yes. 0 No
Has the plignichut been contacted about this complaint?
117 Yes, CI No ,,.
Dates of Treatment
%
,
Desaibe your complaint bete or attach. If you need more seacS continue on reverse or on another sheet of paper.
UriS
eatthP. atrathitxr4
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Date: 3
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Commonwealth of Massachusetts
:5%" 6)
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REDACTED COPY
April 3, 2003
Alain L ster Campbell, M.D.
9 Bos n Street, Suite 9
01904
Lynn,
Docket No: 03-075
Dear D . Campbell:
e Complaint Committee of the Board of Registration in Medicine met on
April
2003 and carefully considered the information both you and the
comp! inant furnished in the above-referenced matter. They determined that no
further action was warranted and the matter has been closed. Despite the
decisio to close the above complaint the Board reserves the right to reopen the
compl= Int should you commit any violations of Board statutes or regulations In
the fu re.
f you have any questions regarding this matter, I can be reached at the
numbe or address listed above.
Very truly yours,
t
l
i
alli
thleen M. Shea
Consumer Protection Manager
KMS1
At nttp://www.messmedboard.org
Commonwealth of Massachusetts
April 3, 2003
Re:
Dear
The Complaint Committee of the Board carefully considered the
inform tion you furnished regarding your complaint against the physician
referer cad above. A copy of the complaint was sent to the physician, who was
require to respond in writing to the Board regarding the Issues that were raised.
after a thorough review of this evidence, the Committee determined that
the co plaint and the physician's response should be placed in the permanent
record of the physician. While the Committee declined to recommend the
initiabc of formal disciplinary action in this case, it is appreciative to you in
bringin this matter to its attention.
hould you have any questions I can be reached at the number or
addres listed above,
hank you ',vain for your concern.
Very truly yours,
athieen M. Shea
Consumer Protection Manager
KM Sls
March 0 , 2003
Ms
Cell M. Shea
Consum Protection] Manager
Board o Registration in Medicine
Boston, A
Dear Ms Shea
Re:
Rocket Number 03-075
Thank y for your hItter, dated February 13, 2003. There is a civil action filed against me
,on the stone allegations, dated August 2002. Her attorney signed
by
himself t of the case recently, due to irreconciliable differences between him and her, so
the case at a
'U for now, the Court having accepted his withdrawal. So I believe
she then ecided to
a complaint with you.
I do
problems td read her handwriting but the comments are the same. as in the civil
action. I surprised she stayed with me from 1991 to 1999 if she was not satisfied with
my
sob to her care.
I am sen g you a copy of the denial by my attorney (1st defense), as the comments are
as well refer to the letter that I prepared for the reviewers, dated
similar.P
10-20-2
1st
Delivery as performed with the usual standard of care, as well as ante-natal care.
diabetes is not an indication for cesarean delivery, neither is a baby 7 pounds 8
Gestati
ounces.
2nd
aint
Uterine ceding was benign and irregular, with no anemia. Problems were diagnosed and
treated edically andisurgically, with the usual standard of care.
3rd co let
I
I comity to offer Medical and surgical treatment of her endometriosis, a chronic and
disease, where
ere both medical and surgical treatment offer silt response rates.1
refused t perform h elective hysterectomy in her case, as explained in the letter dated
10-20I told her other gynecologists could opt for an hysterectomy, but I would not
perform myself. Het bleeding could have been controlled by endometrial ablation. I have
no notio of a significant fibroid in her case
, she had itandard medical care and was treated medically and surgically for
In
her end etriosis and bleeding. She had a normal vaginal delivery for her beautiful
daughter
if"
; sees my answers, it will give her an edge in court against me
I believe
as the ainents-answers will be the same.
asking the Board to suppress her right in the actual circumstances to see my
I am
answers. he could see them after a Court decision is reached. She could in fact use this
complain as an excuse to have access to my defense pre-trial.
erMain L
cc: Esq s harles P Reilly III, Martin, Magnuson, McCarthy & Kenney
101 erritnac St, Boston, MA 02114; 617-227-3240
COMPLMNT FORM
and
Flame
all of theInformation
orient Phone
Home Phone
oyu
Zip Code
Business Phone
Name ant Location of Health Care Facility (if known)
rotational Misconduct
O '
hfiscenduct
O
or Discourteous Behavior
by'Aleohol or Drugs
13
by Mental or Emotional illness
O
allure to Provide Medical Records
04M:dice! Records
SIO :
alaefe side
0
0
Drug Dealing
o
CI
C
O
ifiter-ei
) 'Pt?-7, 0
Ote.the K
01:6
jharir
Failure to replete and de this release may prevent investigation of your cony/Mat
Release of Medical Records and Information
Patient N
Date of Birth:
Address:
I HEREB AUTHORIZE ANY AND ALL HEALTHCARE PROVIDERS OR INSTITUTIONS TO RELEASE
ANY
ALL OF MY MEDICAL RECORDS TO, AND TO DISMSS MY MEDICAL CARE WITH, THE
MASSA SETTS BOARD OP REGISTRATION IN MEDICINE,
Signature Patient
dve)
(Or Legal
Date: 19.
67 2ea3
r FUR
AUIRORTES MY MENTAL HEALTH PROVIDER(S) TO DISCUSS EVALUATIONS,
MAGNI OR TREATMENT AND/OR RELEASE ANY AND ALL OF MY MEDICAL RECORDS TO THE .
MASSA suns BOARD OF REGISTRATION IN MEDICINE. THIS AUTHORIZATION REPRESINIE
WAIVER a F THE PSYCHOTHERAPIST-PATIENT PRIVILEGE, AS DESCRIBED IN G.L. c. 2333 208.
Date:
Signature f Patient:
'ye)
Mt Legg
6. c7211/3
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If you
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Pr,- itot-J-i YA
Mach copses of related documents to ' form.
AV
fr
The mfom>ation in this complaint Is true, correct and complete to the best of my knowledge.
0 Date: AS.
Your s are:
Mall this tbrm to:
57 2.0a3
Commonwealth of Massachusetts
MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
MARTIN CRANE, MD
BOARD CHAIR
NANCY ACHIN AUDESSE
nceNcnvE DIRECTOR
May 4, 2005
REDACTED COPY
Alain Lester Campbell, M.D.
9 Boston Street
Suite 9
Lynn, Massachusetts 01904-0000
Re:
Docket Number: 05-035
Dear Dr. Campbell:
The Complaint Committee of the Board of Registration in Medicine considered
the above-referenced complaint at its meeting on May 4; 2005.
The Board reserves the right to reopen this complaint should you commit any
violation of the Board statute, regulations or policies in the future.
Sincgrely,
Commonwealth of Massachusetts
Re:
Dear
The Complaint Committee of the Board of Registration in Medicine met
and carefully considered the information you furnished regarding Dr. Campbell.
A copy of your complaint was sent to Dr. Campbell, who was required to respond
in writing to the Board regarding the Issues that you raised.
After a thorough review of the evidence, the Committee determined that
your complaint and Dr. Campbell's response should be placed in his permanent
record
While the Committee declined to recommend the
initiation of formal disciplinary action In this matter, it is appreciative of your
actions in bringing this matter to its attention.
Should you have any questions I can be reached at the number or
address above.
Very truly yours,
Jennifer A. Br
Consumer Protection Coordinator
JAB/bmh
Enclosure
Commonwealth of Massachusetts
KERRY HEALEY
LIEUTENANT GOVERNOR
MARTIN CRANE, MO
DoARD GRAM
NANCY ACHIN AUDESSE
EXECUTIVE DIRECTOR
0, OAAA4;
nnifer A.
sumer Protection Coordinator
JAB/som
LC)
Commonwealth of Massachusetts
(0
MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
MARTIN CRANE. MD
BOARD CHAIR
NANCY ACHIM AUDESSE
EFECUTIVE DIRECTOR
Re:
Dear
Your complaint regarding the physician named above has been received.
The physician involved has been asked to respond in writing to your complaint.
Any future correspondence regarding your complaint should include the name of
the physician and the docket number as it appears in this letter.
If you wish to bring additional information bearing on your complaint to the
attention of the Board, please furnish It in writing to me at the address above.
Very truly yours,
a. kiit(6-9
nifer A. Brown
Consumer Protection Coordinator
JAB/som
http://www.massmedboard.org
0
ID
Commonwealth of Massachusetts
to
KERRY HEALEY
UEVTENANT GOVERNOR
:0
MARTIN CRANE. MD
BOARD CHAIR
NANCY ACME AUDESSE
EXECUTIVE DIRECTOR
Re:
Dear
Enclosed please find a copy of Dr. Campbell's response. You will be
notified when there is a disposition in this matter.
In the meantime if you have any questions, I can be reached at (617) 654-9800 ext. 4033
Very truly yours,
Jennifer A. Brown
Consumer Protection Manager
JAB/bmh
Enclosure
(41
It
Dear Ms Brown:
Re:
, 05-035
Thank you for your letter dated 01-26-2005, post marked 01-27-05 and received 0201-05 (office is closed on Monday, weekend in between).
As you indicated in your letter, my answer may be as brief or as lengthy as I choose.
The nature of the complaint involves 5 main items: substandard medical care,
professional misconduct, rude or discourteous behavior, patient neglect/abandonment,
unlawful discrimination. These complaints imply a patient- physician relationship.
I could terminate my letter here stating that a patient-physician relationship was
never established. Thus the complaints are rejected. She came for an elective
termination of pregnancy and I refused to do it. In fact, we did not even review her
medical history.
Women can choose their physician, likewise, physicians can choose their patients for
an elective procedure.
However, with respect for the Board of Medicine, who has to answer to all letters
they receive, I will make some comments.
As quoted by Joanne Tetrault, MA, with Joan Roediger, JD, LLM in Physicians
Practice, January 2005: Severing the ties, how to end a patient relationship legally (p.73):
"to establish a physician-patient relationship, both parties must voluntarily consent
to it, and the physician must indicate an intention to treat the patient."
I refused to see
All of her comments in this letter were negative. I perform 400 to 500 abortions a
year. If all the experiences were negative, the Board would be inundated, monthly, with
letters of complaints that I could not defend. I am a board certified obstetriciangynecologist, I still practice general gynecology and my patients are happy.
I will make comments in the order of the facts that she is referring to. The secretary
was absent that day. The nurse (
) and myself decided we would see the potential
candidates ourselves.
I was part of a group of three different people who arrived
late and at the same time.
I am registered at City Hall in Lynn as Akin Campbell, MD, DIM Atlanticare
Ob/Gyn and Alternative Medical Care. I function as an individual, not a clinic. This is my
private office where I see established general gynecology patients, which are at times
mixed with pregnancy termination appointments.
My waiting mom was completely rebuilt around 1 th years ago, following water
damage. It is modem and clean. I understand that it may not have the nice appearance of
some of the buildings in Cambridge, where ]
lives. Many of my patients come
from Lynn, Lawrence and Lowell. These are poor areas, but people have a right to be
treated no matter where they live. People may have more of a tendency to let
advertisement tags in magazines drop to the floor, without picldng them up so we do
clean more often, after office hours. There are, at times, children playing on the ground,
as some of these customers have no money to pay for a baby sitter. I do not know if there
were children the day she came. I enclose a digital picture of the waiting room.
A private medical office is not an airport: people do not have to show a picture
identification. Verification of age is not necessary unless the woman appears young. In
such a case, it will be done in room #1, privately by the nurse or the nurse-assistant, not
in front of everybody. This is a standard medical practice. When people schedule an
appointment, different forms of payment are discussed. Insurance data do not belong on
the consent form. As elective pregnancy termination is a one time surgery, and usually
people will not return, they will sign directly on the insurance form (HCFA-I500) that I
explain myself just before the surgery, when I review the medical chart. A social security
number is not mandatory on this font. As you can see, many of her comments come from
her ignorance of the medical technicalities of the daily practice of medicine.
Her comments about being asked no question about her name, background, age,
health is irrelevant as that information was supplied by her in the chart, but we never got
to that point as I refused to see her as a patient. We do not offer any counseling as we do
not have the expertise to do so. We refer women in need of these services to Planned
Parenthood in Boston. K over thephone, we realize that a woman is unsure of her
decision, or if we realize at the office that she is unsure honour of her questions, we refer
her to Boston.
told
she had questions for the doctor, so she bypassed room #1
(where a first screening is usually done by the nurse or nurse-assistant) and she came
directly into the procedure room.
0
0
to
My "hands incrusted with white paste" are powder residue from the gloves I had just
removed before seeing her (no infectious material handled), and from the repeated hand
washing throughout the day. As is the case with all physicians, I obviously do take a bath
daily and clean my nails. I wash my hands in between patients and clean the nails
(medical students are taught early to do so). I do not wear gloves when I speak to a
woman or review her medical chart (1
letter suggest it was a mistake not to do
so).
Her medical history, that I did not review with her, shows a history of active
depression.
was upset that I refused to enter a physician-patient relationship with her,
hence a negative letter to the Board of Medicine.
As said earlier, a woman can choose her physician. Likewise physicians can choose
their patients for an elective pregnancy termination. As a physician, I cannot be forced to
perform an abortion when the woman appears greatly concerned of potential
complications or unsure of her decision to terminate a pregnancy. As well, patients with
potential risks, physical or psychological, anent good candidates for office surgery.
"p
Alain Campbell, MD, MSc, Diplomate ABOG
8
m0
Commonwealth of Massachusetts
Board of Registration in Medicine
560 Harrison Avenue, Suite 0-4
Boston, MA 021113
COMPLAINT FORM
Please type or print clearly, and provide all of the information requested.
O Mrs. Your FS Name
Your Last Name
Patient Name (if different)
t
Ms.
Street Address
City
Zry Cone
ktusTnessfDaytime Phone
Bane Phone
0.0
Acupuncturist
.
Complaint againstMD.
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contact the Division of Regbtration 14 (617)7274404 or 239 Causeway St., Boston, MA 02114.)
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Full Name (First & Last) of Physician or Actemecturist (one name per form) Photocopies we acceptable.
Alain L. Comp
M b-
Address
City
MA
Ltirm
Business
901
SI a
Zip Code
svo
0110+
44/11*-
A+
6'4 tate
Nature ()Momplaint
I.
0
anti /o r
01161 N
A 1 4074 ve
Metitc4 f
Cot
Drug Dealing
Criminal Conviction
Patient Neglect/Abandonment
Unlawful Discrimination
Billing for Services Not Rented
Failure to Supervise Staff
False Advertising
"moor- gvesitons
(sea, AW
sUenti4)
Failure to complete and sign this release may prevent investigation of your complaint.
1
Patient Nam&
. Date
. of Birth:
. . -r.
Address:
I HEREBY AUTHORIZE ANY AND ALL HEALTHCARE PROVIDERS OR INSTITUTIONS TO RELEASE
ANY AND ALL OF MY MEDICAL RECORDS TO, AND TO DISCUSS MY MEDICAL CARE WITH, THE
MASSACHUSETTS Mann AR mintstnATiON IN MEDICDAE..
Signature of Paled*"
(Or Legal Repress:MGM
Dale: f /!5/5
C6
Date:
Please list the parses ad atoms of all healthcare plovidons and 'reap:dons that providod *raiment valid' may relate lode complaint
Akuh L. GrArLdli
9 Bos4r) S4. Su1le..1
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Ryon arc not the patient, what is your relationship to the patient?
0 Spouse, 0 Parent, 0 Child, 0 Other Relative
Cl Friend, 0 Attorney, 0 Other
Has this phystesaifvided treatment in the past? (Do not count the treatment in thiscomplaint)
Cl Yes,
o
Is this physician Anon you (or patient) usually see when you (or patient) are up
a Yes, o
dill POI thfl
k4
Row lonAhave you (or patient) been under this physician's care?
s
t I to 30 days, 01 to 12 months, Q 1 to 2 yens, 0 2 to 4 years, 0 4 to 8 years, 0 8 years or more
What form ofpaymad was made? Check as many as apply.
0 Commercial Insurance, 0 Health Maintenance Organization, 0 Medicaid, Cl Medicare, 0 Champus
Workers' Compensation, 0 Sett 0 Other
Ate you (or patient) expected to pay a portion of this bill out of pocket?
CI Yes, 0 No
Has the physician adjusted the bill in any way, for example, was the fee or copayment reduced or waived?
0 Yes, 0 No
Is the fee or copayment in dispute?
0 Yes, 0 No
Has the physiam,beert contacted about this complaint?
Yes,aVo a
ct
00_ 5
Dates of Treatment
41411
Describe your complaint here or attach. If you need more space, continue on reverse or on another sheet ofpaper.
sae s~
44.1.44 41401124
464
Li
u
Date. )/15/;00f...
Your signature:
Mail this form to:
I waited unto 4:50 when I was finally called in to a backroom. I was asked no questions
about my name, my background, my age or my health. I was not given any counseling
about the procedure.
As I walked into the OR I noticed the patient who had gone in before me slumped
over a broken down easy chair in a makeshift hallway "recovery-room" monitoring her
blood pressure. I was taken to the O.R. with my partner and told by nurse to get wrapped
in a tissue gown. I said that I would like to ask the doctor a few questions before the
operation for surgical abortion. She said, fine, he would be right in. As I waited I put on
my gown and noticed that the O.R. was filthy there was dust on all the equipment, and
the countertop. The floor bad dirt stains on in the center of the room (around the table)
and the outskirts were dirty with bits of dust, hairs and debris. Also it was very crowded
and there was broken-seeming equipment lying around. The garbage can was
overflowing.
Dr. Campbell came in and introduced himself. He said that he had called my
insurance agent himself and that I was covered. He said, "Let's begin." I said I had a
couple questions. First I asked about the risk of infection and/or complication and also
about what recovery would be like. He said he did not need to answer my questions since
all pertinent information was included in the consent forms I had already signet I
noticed while he was talking that his hands encrusted with white paste and his nails were
dirty. He was not wearing gloves (though hopefully he would have put them on later). I
persisted and said I really would like to know more about risks and also whether or not he
had had a higher or lower than normal rate of complications from this procedure. Dr.
Campbell would not answer my question beyond directing me to the papers to read. He
said "this a risky operation and I won't say anymore about this. If you are so worded you
should just have the baby." My partner then said, "Dr. Campbell, if you won't talk about
risks, can I ask you if you've had greater than normal problem with malpractice."
Dr, Campbell looked very upset. He turned to me and said, "That's it. I won't
speak about this any more and you will not be my patient. I won't take a risk on
somebody like you. This is an elective abortion and so I choose not to perform it. Get
your things, put on your pants and get out of this office immediately!" Dr. Campbell then
stormed out of the O.R. I scrambled to get on my pants and left the clinic.