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Commonwealth of Massachusetts Board of Registration i

Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-308 http://www.massmedboard.org

Physician Registration Renewal Application "

rrt

ttiVe IC I Fat

Before proceeding, please read the instruction booklet. Copy this form and all attachments for your own record ; vou will need copies for credentialing and other purposes. This completed renewal form with attachments sustst-henclarEerrilfe DV

green envelope 4 weeks before your renewal date.

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u

I

• Remit 5250.00 for renewal fee. • Add late fee of $25.00, if necessary.

• Return renewal application in GREEN envelope. • Enclose check with coupon in BLUE envelope.

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

Renewal Dale: 04/28/2001

If you want to change your current status, please check one of the following boxes to indicate your dew status: (Check only one)

Active

Retiring (see instructions)

Inactive (see instructions)

9 Do not wish to renew

2. Other 4atne(s), if any, under which you were licensed

3 A) Mailing/Business Address:

ALAIN LESTER CAMPBELL 9 BOSTON STREET

SUITE 9

LYNN. MA 01904-0000

B) Home Addrecc-

Home Phone:

Business Phone:

Date of Birth:

  • 4. b) Sex:

a)

M

c)

SS#:

  • 5. Name of Medical School:

a)

b) YkifffictaigEs"Y Faculty er MlS:

1976

M.D.

  • 6. Specialty Code(s) (See Table 1)

Coders)

Hours Der Week in Mass.

4O

OBG

o

Obstetrics and Gynecology

0

Please make corrections (type or print)

Other Name(s):

Mailing Address:

Citv/Town:

State:

Country:

Business Address:

City/Town:

State:

Zip:

Country:

Business Telephone: (_5

5 44-7 3.0120

home Address:

Cityrfown:

State:

Zip:

Country:

home Telephone:

PLEASE NOTE: No P.O. Box addresses for home or business addresses.

  • 7. Cur ent American Board of Medical Specialties Certification (See Table 2)

 

oicode:

Code:

  • 8. Drug License Numbers. if any:

a)

Federal (DEA):

b)

Massachusetts:

  • 9. a) Other states where you are now licensed to practice (Abbr.)

b) States where you were previously licensed (Abbr.)

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 / -- (AP)

Facility Code:

_ ___ If 999, print name(s):

/

(AP)

10 % Facility Code:_

% Facility Code:

.3 6/ i,"" (AP) / 0 % Facility Code:

/

(AP)

% Facility Code:

_/

/

(AP) _ %

(AP)

'N.

VAIN I YOUR L.Aalp4A1VIL:

"I'll( f L./C. I

....

tr

"' I -1 ---E,:- ii.n

r--

ay

......

S.)

• .

fs .' •

1.E., Mintema practice insurance is covered by a) Er-Insurance Carrier

.d'

Name of Insurer: 'PRO m UTujtL 4 I -

102-2-

LICti•ilbt. NUMBER: tUarrii

b)

0

Letter of Credit '

I

Alternatively, indicate as follows:

.,

I am registering with Active status but I am not coveted by medical malpractice insurance because 1 am (check one)

a) CI 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 ('14o

  • 13. A. What is your principal work setting? (See Table 4)

/

5

B. Care of patients in Massachusetts (see instruction booklet).

1) Average weekly hours involved in:

a) outpatient care

35.— hrs/wk b) inpatient care

2) What is the approximate percentage of your patient care hours in primary care?

5--

5

hrstwb

PART A — OUESTIONS REFER ONLY TO THE PAST TWO (2) YEARS

Ouestions 14 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 except for question 22. Refer to the instruction booklet for additional information and

definitions. You must answer ALL questions. or this form will be returned to you and your license renewal may be delayed,

YES.

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

No

CME Waiver requested (CME waiver form due 30 days prior to date of license expiration)

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

Commonwealth of Massachusetts Board of Registration in Medicine

Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320

Physician Registration Renewal

Before proceeding, please read the instruction booklet. • Copy this fonn and all attachments for your own records; you will need copies for credentialing and o

• Remit 5250.00 for renewal fee. • Add late fee of S25.00, if necessary.

Return renewal applicatior in t

BNiciaMtsfe.

Enclose check with coupon n BEIGIskrAcloas Mod

Registration No.: 60491 Renewal Date: 04 /28/1999 I. Current Status:

If you want to change your current status, please indicate below: (Check one).

0 Active 0 Retiring (see instructions)

  • 2. Other Name(s), if any, under which you were licensed:

3 A) Mailing/Home Address:

ALAIN LESTER CAMPBELL, M.D.

B) Business Address:

ATLANTICARE OB/GYN 9 BOSTON STREET EAST LYNN, MA 01904

Home Phone:

Business Phone:

(781)592-3000

4. A) Date of Birth:

B) SS#:

Sex:

M

  • 5. A) Name of Medical School: McGill University Faculty of Medicine

13) Year Graduated: 1976 C) Dame: MD

  • 6. Specialty Code(s) (See Table I)

0 Inactive (see

below')

El Do not wish to renew

 

Please make corrections (type or print)

 

Other Name(s):

 

Mailing Address:

 

q

Zosroal S

Sag& 7

City/Town:

.i-- Y./V Al

 

State ' MAA.

zip:

0190V-

 

country:

 

ilSii-

Ivoiire,.:-ke.tiltss

as: par c 42cet-dre

-

 

Other Address:

 

City/Town: _

"

 

........

State:

.

 

_

Zip:

"

...

Country:

Home: t

 

Business: (

)

Date of Birth: (M/D/Y):

/

/

Sex :OM

0

F

SS#:

Full Name of Medical School:

Year Graduated:

Code(s)

Degree: 0 M.D.

0 D.O.

Hours Per Week in Massachusetts

  • 450 Hair Peggilla tistslis and Gynecology

If OS, Print Spezia ty:

  • 7. Current American Board of Medical Specialties Certification (See Table 2)

Code: OG

Code:

  • 8. Drug License Nurnberg if anv'

  • A) Federal (DEA):

  • B) Massachusetts:

  • 9. A) Other states where you are now licensed to practice Abbr:

    • B) States where you previously were licensed to practice Abbr.

Code:

Code:

Federal (DEA):

Mass:

Abbr:

Abbr:

•If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts.

PRINT NAME AND NUMBER: Last Name: CA MPA£ 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.

Facility Code:

S

(Al')

% Facility Code: __

yzi e./(AP)% Facility Code:_1141 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

Nam e of Theurer: has AL r

/Bra'.

hts

rn lc rte. m

ite

/erns

dhomee.—

n 2(

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) 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

2) What is the approximate percentage of your patient care hours in primary care?

(0

'Ye

4- hrs/wk

PART A — OUESTIONS REFER ONLY TO THE PAST TWO (2) YEARS

Questions 14 through 22 refer to the oast two (21 years only. Check either YES or NO (NOT N/A) to each question. Provide details on Form R for all YES answers except for question 22. Refer to the instruction booklet for additional information and definitions. You must answer ALL questions, or this form will be returned to you and your license renewal may be delayed,

YES NO1

  • 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?

IS. Have you been formally 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 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 reason?

  • 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?

1

  • 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

l al‘ 79

YOU MUST SIGN AND INCLUDE PART B, PAGE 3, WITH YOUR RENEWAL APPLICATION

Commonwealth of Massachusetts Board of Registration in Medicine

Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320

Physician Registration Renewal Application

Before proceeding, please read the instruction booklet.

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.

Remit $250.00 for renewal fee.

Add late fee of $25.00, if necessary.

• Return renewal application in GREEN envelope.

• Enclose check with coupon in BLUE envelope.

Registration No.:

I. Activity Status:

(Check only one)

60491

Renewal Date:

04/28/97

['Active

0 Inactive *(see below)

0 Retiring (see instructions)

0 Do not wish to renew

2. Other Name(s), if any, under which you were licensed:

Corrections (type or print)

Other Name(s): .. 3. A) Mai ling/Home Address: Mailing Address: City/Town: State: ALAIN LESTER CAMPBELL, M.D.
Other Name(s):
..
3. A) Mai ling/Home Address:
Mailing Address:
City/Town:
State:
ALAIN LESTER CAMPBELL, M.D.
Zip:
Country:
B)
Business Address:
Other Address:
ATLANTICARE OB/GYN
9 BOSTON STREET
LYNN, MA 01904
City/Town:
State:
Zip:
Country:
Home:
(
)
Home Phone:
Business: (
)
Business Phone:
(617) 592-3000
Date of Birth (M/D/Y):
/
/
Sex (M/F):
4.
A) Date of Birth:
C) Sex:
14
Lic. Issue Date (M/D/Y):
/
/
55th
B) Lic. Issue Date:
10 /19/88 D) 5S14:
Full Name of Medical School:
5.
A)
Name of Medical School:
McGill University Faculty of
Medicine
Year Graduated:
Degree (MD/DO): _
B)
Year Graduated:
76
C) Degree:
MD
6.
Specialty Code(s) (See Table I)
Code(s)
Hours Per Week in Mass.
Hours per Week in Mass.
0
a CD
Code(s)
go °tor-Emu AAA &swede:*
s•
OBG
64 Obstetrics and Gynecolo
If OS, Print Specialty:
7.
Current American Board of Medical Specialties Certification (See Table 2)
Code:
Code:
Code:
OG
Code:
8.
Drug License Numbers, if any:
Federal (DEA):
A)
Federal (DEA):
Mass:
B)
Massachusetts:
9.
A) Other states where you are now licensed to practice
Abbr:
Abbr:
B)
States where you previously were licensed to practice
Abbr:
Abbr:

*If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts

PRINT NAME AND NUMBER: Last Name: CittA P ?;€ LL-

Registration Number:4 0 4/qt

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:

___

If 999, write Neme(s):

Facility Code:

Facility Code:

Facility Code:

___

11. My medical malpractice insurance is covered by a)

Name of Insurer:

ItilitaLCAIII OWc

Insurance Carrier

b) Letter of Credit

d roAt-

Facility Code:_

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)

Not involved in direct/indirect patient care in Massachusetts b)

Please explain exemption:

Otherwise exempt

12.

Are you currently in a post-graduate training program in Mass. as a resident or clinical fellow? (check one)

0 Yes Vigo

13.

  • A. What is your principal work setting? (See Table 4)

5

 
  • B. Care of patients in Massachusetts (see instruction booklet).

I) Average weekly hours involved in:

a) outpatient care

3 it— hrs/wk

b) inpatient care

fa hrs/wk

2) What is the approximate percentage of your patient care hours in primary care ?

5

%

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:

 

YES

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?

 

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

(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.

RENEWAL APPLICATION CONTIN ED ON PAGE 3. ALL QUESTIONS ON PART B MUST BE ANSWERED.

Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1995.1997 Physician Registration Renewal Application

Registration No.

Status

Fee

Renewal Date

Late Fee

_60491

irmtvn $250.00

04f213/95

U SA

Mailing Address:

Address (Mailing):

ALAIN LESTER CAMPBELL, M.D.

 

City/Pow=

 

State:

Country:

Coriecdon of Mailing Address

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

3. Date of Birth:

Sex: M

Lic. Issue Date: 10 /19/88 SSC

Jinnut Phnnr

  • 4. Name of Medical School:

ihntinMahigis

(617)592-3000

McGill University Faculty of Medicine

Year Graduated: 76

Degree: IC

Corrections of Pre-Printed Information

Name:

ii-r-A -NTI

'

06 alit)

 

Address:

g-

--*

it

4.,

City/Town:

rod

State:

Country:

Ail

:

(.154

Zip. —.122LIELV----

Date of Birth (MAW):

/

/

Sex (WP):

 

Lic. Issue Date (M/D/Y):

/

/

SS#:

Home: (

)

Business: (

)

Full Name of Medical School.

 

Year Graduated:

 

Degree (MD/DO):

 
  • 5. a) Other states where you are now !leaped to practice (Abby): t O N

b) States where you previously were licensed to practice (Abbe):

ue.6

gli e*Wittok

  • 6. Specialty Code(s) (Set Table I):

Code Hours per Week in Mess.

Code

' OBG 64 Obstetrics and Gynecology

If OS, print specialty

Hours per Week in Man.

  • 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

  • 9. Activity Status: I am applying to be registered with the following status: ACTWE

Code:

Federal (DEA).

Mass.

INACTIVE

Code:

• I hereby certify that if requesting Inactive status, I will not practice medicine, includbm writing prescriptions, In Massachusetts.

PRINT NAME AND NUMBER: Physician Last Name:

OttintkP StLL

Registration Number: e 411'l

10. a) Current health care facility(ies) at which you have completed the crecientialing process for the provision of patient care. Supply the

codes from Table 3 and place a heck ark next to those facilities where yo Ahave admitting privileges (AP).

Facility Code: _C2 _L

Facility Code: _

=

 

(AP) Facility Code:

san

..

(AP)

-.4.

 

/

(AP) Facility Code: — /

(AP)

Facility Code: —

/ (AP)

Facility Code:

(AP)

If 999, print name(s).

b) Additional hospitals at which you previously held privileges and other health care facilities with which you were associated in the past 2 years.

(See Table 3)

Facility Code: _ Facility Code: _ Facility Code: —

If 999, write ncune(s).

Facility Code: Facility Code: _

11.My medical malpractice insurance is covered by (a) Insurrace Carrier

List Insurer MAd cve- M N.9 • -496.-1 Unclxik/a

(b) Letter of Credit

it 55

M A-

If applicable, check one,

Alternatively, indicate as follows: I am registering with ACTIVE status, but I am not covered by medical malpractice insurance lvv.sose I am

(Check One): (i) Not involved in direct/indirect patient care in Massachusetts.

State how otherwise exempt.

(ii) Otherwise exempt:

12. Are you currently in a post-graduate training program in Mass. as a resident or clinical fellow? Yes

No X. (Check one)

13. a) What is your principal work setting? (See Table 4)

  • b) Care of patients in Massachusetts (See instruction booklet.)

i) How many hours per typical week are you currently involved in outpatient care in Mass?

hrs/wk

How many hours per typical week are you currently involved in inpatient care in Mass?

hrs/wk

  • c) Approximately what percentage of your patient care hours are in primary care? (See instructions for definition of primary care.)

%

Questions 14 through 24 refer to the past two years only. Check either YES or NO (NOT N/A) to each question. Provide details on.

Forma R-1 and R-2 for all YES answers Refer to the inatn , eNman book) t Ion additional infnrmo_H,+ a and deflnitlons.

IN THE PAST TWO YEARS:

tut ND

14.CLAIMS MADE: Has any medical malpractice claim been made against you which has not yet been finial./ wittim en. • ..

adjudicated, whether or not a lawsuit was filed in relation to the claim?

.4

15.CLAIMS RESOLVED: Has any medical malpractice claim against you been settled, adjudicated or o

whether or not a lawsuit was filed in relation to the claim?

atbitred.

16.Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, or your pro-

fessional conduct in the practice of medicine, been filed against you by a patient, 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 formally charged with or disciplined for any violation of the rules, by-laws or standards of practice of any

govemmemal 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 reason?

  • 21. Has any professional liability insurance provider restricted, limited, terminated or imposed a surcharge on your coverage or

have you voluntarily restricted, limited or terminated your insurance coverage in response to en inquiry by a professional

liability insurance provider?

  • 22. Have you been diagnosed with or do you have a medical condition which limits or impairs your ability to practice medicine?

23. Have you engaged in the use of any chemical substance(s) which in any way interfered with your ability to practice?

24. Have you voluntarily modified or otherwise limited your scope of practice of medicine for any reason other than a medical

condition?

  • 25. I have completed my CME requirements in the two years preceding my renewal date: Yes No, training program exemption (see instruction booklet)

No waiver requested

If requesting a waiver you must fill out a separate Waiver Form. The waiver must be granted by the Board before your license will be

renewed. See instructions for CME requirements. Do not submit documentation of your CMEs with your renewal application.

Pursuant to G.L. c. 112, sec. 2, I will not charge to or collect from a Medicare beneficiary more than the Medicare reasonable charges.

• Pursuant to G.L. c. 62 C, see. 49A, I hereby certify under the pains and 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 United States.

• Pursuant to G.L. c. 112, sec. 1A, I hereby certify that I will fulfill my obligation to report abuse or neglect of children as required by

c. 119, sec. MA.

• I hereby certify under the pains and penalties of rjury that all Information on this form and Forms R-1 and R-2 is true.

Signature:

Date: oi /AS

I.' PHYSICIAN INFORMATION

ODZZ.UUVU

ALAIN LESTER

CAMPBELL

First Name

Middle Initial

Last Name

Sex

Make changes to name here

Mass License fi 09.49.1

License Status Active

Atlanticare Ob/Gyn

225 Boston St,Suite 205

Lynn, MA 01904

U.S.A.

(617) 592-3000

Hospital Affiliation

AtlantiCare Medical Center

First Issue Date 1.6/19/8$

North Shore Medical Center-Salem Hosp

Make address eu,reciions here: z. A

LAN I I eith,

oSibl

05.17.00

1.114N

M.o.t 40

C61.1/ 5-ci

3.00.

Insurance Plan Affiliation:

AttikvaRia

Fit -Bic Es

ift.g.whutaff fr

y

tuf.o,tf

.17f.o1.Mattetink.s.kattcAlb

II. EDUCATION & TRAINING

Make any corrections to above here-

Licenses fkid in Other States:

(Please correct as necessary)

Accepting New Patients? %yes

No

Accept Medicaid?

[Wes ETI No

McGill University

University Faculty of Medicine

IlidicaSehool

MD

Degree

76

Date

Make corrections here it &fa UAL ettent - kom1121.a theittbsi. tettsh nit • silei045ft Csepel/ft ti6spnix Atifry 14.2 fir,

Residency Programs)

stbspagsail rr itornitiAL Csoetm. vugesesk( -v.ge4041

Residency Program(s)

Potvinal of

lierscebilo

Stan

lltnisafet.) ji-eseiretc 4vtC q•q--

Start

End.iast 4-7

End --)U Non

20--turnivg, ItesP-Thttlisiti (tAnPA Nivcy In End 411168-0

Residency Program(s)

Start

III. SPECIALTY

Primary Specialty: Obstetrics and Gynecology

Secondary Specialty:

Make any corrections here:

BOARD CERTIFICATION

Certifying Board Name: Board of Obstetrics and Gynecology

Certifying Board Name:

Make any corrections here:

Board of Registration in Medicine

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)

Date

DiQciplinary Action

VI. CRIMINAL CONVICTIONS The Board of Registration is unable to obtain accurate data for this category at the present time. This information will be included when the court system is Rah, computerized. Please list any criminal convictions. Include conviction date and nature of complaint

VII.

MALPRACTICE

No. of Years in Practice: #

Details of claims paid for Dr. CAMPBELL

Date

Amount Paid 0.0000

Basis for Complaint

Date

Amount Paid

Basis for Complaint

Date

Amount Paid

Basis for Complaint

Date

Amount Paid

Basis for Complaint

Date

Amount Paid

Basis for Complaint

Date

Amount Paid

Basis for Complaint

VIII.

PHYSICIAN HONORS & PEER-REVIEWED PUBLICATIONS

Please enter any peer-reviewed publications to which you have contributed and any awards for community service or professional recognition you have been given.

Awards, Honors

Publications

(q12 trobEarsitip, No-omtt Astifecil etypiert oremibM

14

R Estfit2t 14 8 ufittg Mc 6/a. titaveheSity

Ve

...

bita3/4

iv Lo41/04

D:A

let% M Sc. dig/S-6 keit* stoat

MtGt41UN14.ERsrrr

Note: Please return the survey In the enclosed envelope to:

Atlantic Associates, Inc., 8030 South Willow Street, Manchester, NH 03103

Board of Registration in Medicine

Physician Profile

Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1993-1995 Physician Registration Renewal Application

Registration No.

Status

Fee

Renewal Date

Late

Fee

60491

ACTIVE

$250.00

04/26/93

$25.00

Mai ling

Correction of Mailing Address:

Address (Mailing):

AAIN LESTER CAMPBELL, M.D.

City/Town:

State.

Country Code (See Table 1).

Directions: Staple check to bottom of form. Add late fee If necessary.

• Questions 1-8 include information from Board files. Please correct as necessary in the boxes

provided on the right hand side of the page.

• Before proceeding, please read the instruction booklet. Some questions are optional.

• 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.

• Enclose the $250.00 renewal fee by means of a certified check, money order or personal check made

payable to the Commonwealth of Massachusetts.

Pre-Printed Information

1.

Other name(s), if any, under which you were licensed:

2. a) Address (Home):

b)

Address (Business):

ATLANTICARE 06/GYN 493 1.ESTERN AVENUE LYNN, MA 01904

3.

Date of Birth;

Lic. Issue Date: 1 / 19/68

Sex:

Rs.:

fel

Telephone Number

1:19Elt

4.

Name of Medical School:

Business

(617)592 - 3000

i•1c3ill University Faculty o f

Medicine

Year Graduated: 7 6

Degree: M

Corrections of Pre-Printed Information

Name:

Address (Home).

City/Town:

State:

Country Code:

Address (Business):

City/Tovm:

Country Code'

Zip.

If 999 print Country.

If 999 print Country:

Date of Birth (M/D/Y)•

Lic. Issue Date (M/D/Y):

/

Telephone Number.

Home: (

)

Full Name of Medical School.

/

Sex (M/F):

SSA:

Business: (

)

Year Graduated:

Degree (MD/DO):

5.

a)

Other states where you are now licensed to practice (Abby):

b)

States where you previously were licensed to practice (Abbr.):

t

Code

Hours per Week in Mass.

6.

Specialty Code(s) (See Table 2):

Code Hours per Week in Mass.

JJG 64 Obstetrics and Gynecology

0

If OS, print specialty.

7.

a)

If you are currently American Specialty Board Certified, enter Codes

Code:

GG

Code:

(See Table 3)

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:

Federal (DEA):

State (MA):

Code:

Code:

9.

1 have completed my CME requirements in the two years preceding my renewal date: Yes

No, waiver requested

You must fill out a separate Waiver Form. The waiver must be granted by the Board before your license will be renewed. See instructions for

CME requirements. Do not submit documentation of your CMEs with your renewal application.

Staple Check Here

PRINT NAME AND NUMBER: Physician Last Name: CA MP Bez-c Registration Number: 6 d 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.

List Insurer

\

NLE. Z0 (NT

thild.gom. ASs .

a

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:

(State how otherwise exempt):

(ii) 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).

Facility

Code:

AA

Facility Code:

If 999, print natne(s).

(AP) Facility Code: _,(2

L /1 (AP)

(AP) Facility Code: — / (AP)

Facility Code:

/

(Ap)

Facility Code: —

/

(Al')

Additional hospitals at which you previously held privileges and other health care facilities with which you were associated in the past 2 years.

(See Table 4.)

Facility Code:

Facility Code:

IM11.1,

Facility Cale: — Facility Code:

Facility Code:

If 999, write name(s).

_

13. Are you currently in a post-graduate training program in MA as a resident or clinical fellow? Yes __

(Check one)

14. a) What is your principal work setting? (See Table 5)

,i_

b) Care of patients in Massachusetts (MA) (Sec instruction booklet.)

i)

How many hours per typical week are you currently involved in outpatient care in MA? It

hrs/wk in MA

ii) How many hours per typical week are you currently involved in inpatient care in MA? .212

hn/wk in MA

Questions 15 through 23 refer in the past two wears only, Check either YES or NO (NOT N/A) to each question.

 

Provide details on Form 15A for all YES answers. Refer to the instruction booklet for additional infommipti,

IN THE PAST TWO YEARS:

 

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

Commonwealth of Massachusetts Board of Registration in Medicin Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1991-1993 Physician Registration Renewal Application

Registration No.

Status

Fee

Renewal Date

00491 ACTIVE

$150

04/28/91

Dr. ALAIN LESTER CAMPBELL

Directions:

Quesfions l-7 include inkonation from Board filet. Please coma it as necessary.

Beim proceeding, please read the Instruction booklet

For Of Use Only

M.R.

/

Pr.

Bk.

Ch.

D.E.

/

I

* 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

Corrections of PrsPrinted Information

1. Other Name(s), if any, under which you ware licensed: Name: 2 e) Address (Home): Address:
1.
Other Name(s), if any, under which you ware licensed:
Name:
2
e)
Address (Home):
Address:
City/Town
State:
Zip:
Country Code:
(If ODD write Country):
2.12) Address ((Business):
Address:
ATLANTICARE OS/GYN
Cityfrovm:
493 WESTERN AVENUE
LYNN. MA 01904-
State:
Zip:
Country Code:
Of 999, write Country):
3.
Date of Birth:
Sex: N
Data of Birth (M/D/10:
T
_____
—/
Sex (WF):
um issue Date: 10 /1 9 / 8 8
SSI4
Lb. Issue Date(M/D/Y):
/
/
SSN il:
Telephone Number:
1391110
&sines
1 7 ) 5 9 2 - 3 0 0 0
Home: (
___
)
Business: (
(
4.
Medical Sthool Code: QU001 Year Graduated: 7 6 Degree:
ID
School Code:
Year Graduated:
Degree (MD/DO):
Name of School:
if 99999, write School.
Faculty of Medicine. McGill Univer
it
5, a) Other States where you are now licensed to practice (Abby):
n o
e
b) States where you previously were licensed to practice (ACM:
Q u
e
iec,
Canada
8.
Specialty Code(s) (See Table 3):
agile Hours oar Week in Mass
gOi
Hours her
In Mass
03G
0 Obstetrics ana Gyneco
I. o )
y
.......
0
If OS, write specialty:
7.a) Are you American Specialty Board Certified? (Y/N) Y
7.b)
If YES
Enter Codes:
cow: OG Board of Obstetrics and
Coda:
Gynecology
Code:
Code:
8.
Drug License Number(s) (if any) (optional]: a) Federal (DEA)_
b) How many DEA nos. do you have? 1
c) State (MA) DM_
D.
I have completed my C.M.E. requirements In the two years emoting my renewal date:
YES
X
Waiver Requested

(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.

som - 9/90 - P813971

( For Office Use Only: Waiver Granted

Date:

/

/_

)

FILL IN NAME AND NUMBER:

Physician tut Name.

CAMPBELL ALAIN LESTER

Registration No ..

60491

  • 10. My medical malpractice Insurance is covered by (a) INSURANCE CARRIER xx or (b) LETTER OF CREDIT

UM Insurer:

MED. MALP. JOINT UNDERW. ASS., MA.

. If applicable, check one.

Alternatively, incieete as hollows: I am registering with ACTIVE status, but I am not covered by medical malpractice Insurance because I am (Chet* one):

(I) NOT INVOLVED IN DIRECT/INDIRECT PATIENT CARE;

Mate how otherwise exam*

_

(II) OTHERWISE EXEMPT;

  • 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;

/

(AP)

Facility Code:S.1_4_60MP)

FacliW Code: _

tJAP)

Facility Code:

/ (AP)

If 999, write Narne(s).

Adddonal Hospitals at which you emulously held privileges and other Health Care Facilities with which you were associated in the put 4 years.

(See Table 5.)

Facility Code:_ 998

Facility Code: ___

Facility Code: _

Facility Code: ---

h 999, write Name(s):

  • 12. Post Graduate Training In Massachusetts (MA) (,esal instruction booklet.)

    • a) Are you currently In a post-graduate training program in MA as a resident or clinked fellow? Wes

No x x (Chick one.)

  • b) if you are in a MA program, are you a I)

Resident

__

U) Clinical Felow

or IN) Research Fellow ? (Check one.)

  • o) How many hours per typical week do you spend In this MA post grad

training program?

tusArk, In Wk.

  • 13. Care of Patients In Massachusetts (MA) (222 instruction booklet.)

    • a) How many hours per typical week are you currently involved in aththent care In MA? 14

hrowk . in MA.

  • b) How many hours per typical week are you currently Involved In inpatientcare In MA? 5 0 hrs.Nrk. In MA.

  • 14. Principal Work Setting.

    • a) What Is your principal work setting? (See Table 6) 10

Question. 16 through 22 refer to the past four veers only. Check either YES or NO (not WA) to gqgg question. Provide details on Fenn 11111

Refer to the Instruction booklet for addtkinal Information.

III

/42

  • 15. Has any pending or new melted malpractice claim been made against you (whether or not a Sault was filed in relation to the dalml?

  • 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 regulations—See 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, edre&

  • C HE COMMONWEALTH OF MASSACHUSETTS

ARD OF REGISTRATION AND DISCIPLINE IN MEDICINE

Application for Endonement Registration

(Fee 5150.00 must accompany APPLICATION — No currency or personal checks)

F ed

s,

/

F-mm a Fee

(4k

1

Pease Print

Na me

Alain

pint

Date of Birth —

Lester

Waddle

For Office Use

Application #

vo X°

Certificate #

Date of Iss um

SWORN STATEMENT

Dam, March 11th, 1988.

CAMPBELL Address7375 de Dieppe Ave.,

lar

Montreal, Quebec, Canada.

Place of Birth St-Hyac inthe ,

Quebec, Can a d a

H3R 2T6

PreMedical Education

Medical Education

School

University of Montreal

B.Sc. : 1969-72

Years Attended

School

McGill University

1972-76 • M.11

y us Attended

previonely, B A. (Univ. Mt1, 1969) e

C.M.

Postgraduate Educatiou • Moattital AMmiadataata

Place

Position

Dater

?DST CR A.DIIATI

EDUCATTONi

14_,Sc (Ex50111nVRI vMelNine - Endocrinology)

Residency

p r o

MpGil

monl. 1 Univ and Univ. Mt1; 1977-80

Appointments: Assistant Prof Cl

into al OB/GYN- ,

frac

-Neale zne and

Graduate Situates, univ-

Leal, 9-Lc itesti

e

and ilatia.1 -Ri P11

List all other states in which you have been fully licensed.

t 1 n ivprsitv Hotpitals; 1981-actual 1988;

QUEBEC, only, Canada 7]-182

Other names under which you have been licensed' none

List Specialty Boards by which you are certified. AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY

1k4 m -

icg

04244 -4

tre\COM

oalm w

Ifrcfrot_44:AM.

L

lrt 1/4/4 itecat

..

4

n. iCeia Ata-W4

t

aA

&1/-4

es"-- 02),

504,

Piv.a.tie, & CertilLAZ - MgAZIi)

kg- &PAR.

(

1-aAkm.

Se0+444: esgart

min

D6/(Y$

tt 1.144:

al-

OUX

4124,0*-14 k`iialLela3/4 Jr:clumutok &aa. CA-at 616113 •

g%'"

AvjL

4

1:A-

fr 1983

Tirs4SAI

(

-)Ci•"-A

4C,_ AA 16 .

41"te"le C'OYIONWIALTH OF MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE SUPPLEMENT TO APPLICATION FOR FUEL .LICENSE

mr

FOR OFFICE US' ',SLY Full License Application Pending Approved License 0

TO BE COMPLETED BY APPLICANT. PLEASE TYPE OR PRINT.

NAME:

Alain

L.

CAMPHEit

PERMANENT ADDRESS: -

LOCAL MAILING ADDRESS IN (MA):

HOSPITAL: Ste-Justine Hospital

ADDRESS:

3175 COTE SAINTE-CATHERINE,

Mnntrpal

H31. IC5

Canada .

YOU ARE REQUIRED TO COMPLETE THE QUESTIONS BELOW.

111 NO

  • 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)?

1.

  • 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?

2.

  • 3. Have you ever applied for licensure or to sit for an

examination or taken an examination, under a different name?

3.

  • 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?

4.

  • 5. Have your ever failed an examination (including the FLEX

Examination) before any state or the National Boards?

5.

  • 6. Have you ever been denied a medical license, whether full,

limited or temporary, for any reason?

6.

  • 7. 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?

7.

  • 8. 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)?

B.

  • 9. Have you ever voluntarily surrendered a license to

practice medicine or any healing art?

The Board's regulations

define "disciplinary action." Please refer to 243 CMR 3.02,

attached.

9.

  • 10. Have you ever withdrawn an application for medical

licensure, hospital priviledges or appointment, for any reason?

10.

  • 11. Have you ever for any reason, lost American Specialty

Board Certification?

11.

  • 12. Have you been denied required recertification by one or

more specialty boards?

If yes, which one(s)?

12.

  • 13. Have you, at any time, been a defendant in any criminal

proceeding other than minor traffic offenses?

13.

  • 14. Has your privilege to possess, dispense or prescribe

controlled substances ever been suspended, revoked, denied, restricted, surrendered or have you been called before

or warned by this state or any other jurisdiction including a federal agency at any time?

14.

  • 15. Have you ever had any emotional disturbance or mental

illness which has impaired your ability to practice medicine

or to function as a student of medicine?

15.

  • 16. Have you ever had an organic illness which has impaired

your ability to practice medicine or to function as a student

of medicine?

16.

  • 17. Are you now, or have you been in the past, dependent upon

alcohol or drugs?

17.

  • 18. Have you ever held a license in Massachusetts or any other

state or country? If yea, list other jurisdictions.

18.

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

Commonwealth of Massachusetts Board of Registration in Medicine

Ten West Street, 3rd Floor, Boston, Massachusetts 02111

  • 008264 4 1 Zf

1969-1991 Physician Registration Renewal Application, Paget of 2

Beard Use Salo:

Registr ation No.

Status

Fee

Renewed Date

6 0491

1150

04/20/89

 

M.R.

ALAIN LESTER CAMPBELL

Pr.

Bk.

, lait sqt1;

Ch.

D.E.

R.

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

form can result In discOintuy action. . Oaf legibly crisps your answers. . Answer all nopoptional questions (front and back of form)compAstely-It is not adequate to state than the Board already hoe the Information. . Sign the renewal application at the bottom of page one and MI in the number of attached pages in the peromph above the signature. . Make a copy of this form and all attachments for your oym records-you mast gee hospitals and other health care facilities copies Sr credentleng mimeses. . Enclose the $150 general Ilea by ammo of a awned check, money order or personal check made payable to the Commonwealth of Massachusetts.

1. a) Name (LAST1

CAMPBELL

(FIRST:)

ALAIN

1.b) Other Berne (a).11 env that you were ever licensed under: NOT APPLICABLE

  • 2. a) Address (Mailing): SAME AS ABOVE

2.b) Address (Home):

  • 2. c) &Wrest) (Business):

SAME AS ABOVE

ATLANTICARE OB/ GIN

495

NESTPRN

AVF

LYNN. MA

. OL9 oq

2.di Telephone (Busirtem): (6 1 L

)

5 9 2- 3 0 00 _ Extension

2 a) Telephone (Home) (Optional):

.

  • 3. 4. Sex: MALE) FEMALE

Date of Birth (140/DA/YR):_

5. Soar) Security No. (Optionaipt

  • 6. a) Medical School Code (See Table 1): Q0001 tr agog, write Name:

  • 6. Year Graduated: 1 97 6

b)

60) Degree: M.D.XX

D.O.

  • 6. Canada X Coda If Other (See Table 2): —

0) Country: U.S.

1199g, write Name:

— — —

 
  • 7. Work Setting (Circle end indicate Peroent(%)of Practice TMs):

 

10

Hospital

15 Private Office

20 Partnership/Group Practice

10

a

25

Clinic

202F'

30 Mental Health Canter

35 Nursing Home

a

40

HMO Facility

45 Educational Institution

50 Medical Society

55

Government Facility

60 Plant/ComMerolal Setting

99 Other

a Professional ActMly (Circe and Indicate Percent(%) of Professional Time):

 

8. b) Mora. Lie Issue Date

10

Resident or Fellow

20 Practice Involving Direct Patient Care

90

%

(see Boar wail °enlaces.)

30

Administrative Activities

40 Medical Teaching

 

(MO /DA/YR):1I 19/ 88

50

Medical Research

10

%

99 Other

  • 9. SpeoWty Code (See TOM 3): jab G Percent of Practice Time: too

%

Specialty Code:

Percent of Practice Time:

 
 

___

if OS, specifr.

10.a) Are you American Specialty Board Certified? N /N) Y

10. bid YES, circle which &midis):

Al

A

Board of Anesthesiology

CRS

D

Board of Dermatology

EM

FP

Board of

Family Rectos

IN

Board of Internal Medicine

NS

(See

Table

4.)

1 0 (46

Facility Code 10 8

 

Facility Code:

a

11

999, write Name(s):

 

(See Table 4.)

Facility Cods,

998

11999, write Ns11114):

q

Qk

Board of Allergy & Immunology

 

Board of Nude.? Medicine

PS

Board of Plastic Surgery

Board of Obstetrics & Gynecology

PM

Board of Preventive Medicine

OP

Board of Ophthalmology

PN

Board of Psychiatry & Neurology

OS

Board of Orthopedic Surgery

Board of Radiology

OT

Board at Otolaryngology

S

Board of Surgery

PA

Board

of

Pelh obov

TS

Board of Thoracic Surgery

PE

Board of Pediatrics

Board of Urology

PMR

Board of Physical Medicine & Rehabilitation

Board of Colon & Rectal Surgery

Board of Emergency Medicine

Board of Neurologloal Surgery

  • 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.

Facility Code:

Facility Cede

Facility Code:

Facility Code:

  • 11. b) Additional Hospitals at which you previously held privileges and other Health Care Fatigues with which you ware associated In the past 10 years.

Fealty Code:

___

Facility Code

kit NI BEM: • S13- - •1/41.15 TUVE'

tut 04.44 Ain't

-%eu

Fact Ay Code: _ Fealty Code: _

LiN ttra 5 Ity

Was PI rof-t.

n/ ties in tot.

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

3 *hotbed clot(-le true.

Signature:

P./ Rhine saw

Date 44

a(

, 'Tr

Massachusetts Board of Registration In Medicine 1989-1991 Renewal Application, Page 2 of 2

Fill in name and number.

Physician Last Name:

ra MPPFTi

  • 12. 41) Other States where you are now Awned to practice (Abbreviate):

Q U

12.b) States where you previously were licensed to practice (Annandale):

13.I am applying to be registered with the following status:

ACTIVE XX

INACTIVE

Registration No ..

6 0 4 9 1

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.)

Category 4O hrs., Category I: 8 n hrs., (Risk-Management 1(1 hrs.), Residency Program In.

Waiver Requested (You must fill out a separate Waiver Form.)

  • 14. b) My medical malpracilespeuranos Is covere4 by INSURANCE CAFIRIER

LETTER OF CREDIT .

insurer:NO) Nfig 41n

amality ML MA Institution ['suing Letter of Credit.

applicable, check one and identify the name,

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

  • 14. c) Percent of Practice Time In Massachusette 10 0 %

OTHERWISE EXEMPTED

_

(State how)

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.

itshtt•OfrOrtt• 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?

yep

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):

COMMONWEALTH OF MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE SUPPLEMENT TO APPLICATION FOR AMERICAN SPECIALTY BOARD

TO BE COMPLETED BY APPLICANT. PLEASE TYPE OR PRINT.

NAME:

CA MP 8 L a_

PERMANENT ADDRESS:

LOCAL MAIUNG:

ADDRESS IN (MA);

C 4 4--

L

(

e_

ALAI

-

FOR OFFICE USE ONLY Specialty License Application Pending Approved License #

HOSPITAL

ADDRESS:

Applying on the basis of which approved American Specialty Board?

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)?

YES NO

  • 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,

U 1)0

TT -1%2-

.

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:

7r

...

/D O&

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)

Bs'

Fwm of Fee

P.'ease Pratt

Name Alain Fos/

Date of Birth

For Office Use

Certificate #

SWORN STATEMENT

Lester CAMPBELL Address

Lau

trivd/e

Place of Birth St-Hyacinthe, Quebec, Ca ada

IQ;

Application #

*1° 7 6

Date of Issuer 91)L'/

Dalt March 11 th , 1988.

113R 2T6

Pre-Medical Education

Medical Education

School

University of Montreal

B.Sc. : 1969-72

Years Attended

B A. (.Univ. Mtl, 1969

School

McGill University

iceilIS A t tended

1972 - 76

• M.D

C.M.

Postgraduate Educed** & Hospital Appointee/ad

Place

POSTGRADHATE

Renirinn_cy

Position

EDU_CATIO_N: M.Sc.

Dates

- Endocrinology)

programs_ OB/GY.N: McGill Univ. and Univ. Mtl; 1977-80

Appointments: Assistant Prof Clinical OB/GYN , rac Medicine anti

ra uate

u les,

List all other states in which you have been fully licensed.

QUEBEC, only, Canada; 77-182

university Hospitals; 1981-actual 1p88;

Other names under which you have been licensed:

none

List Specialty Boards by which you are certified.

AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY

..

D

csusrA 1. ac kz:tte ifitAAA. 4.i-_14,,

L . m , c c . at , 1/4 t. x

..

.v- ;

Pik &

cer-mais.

Isar -4 ei--- co.

10 t,-P # 01- 1C0LAAP-L AAA tnate a4, t:(1.6 eig;,,u

iq sm. 41-v1.4AA:

/4

eavb‘

g

(

tw4.sk9-- a_ artk. /fa mutAZV lo

kstAcca-e. Cadr• 1 'cm ktw. ,

ZPAA ar.AA 00,. , en

af3/cytO

t

ee-

1 I

rig: :c

atuve

-,A,

tkokilaLegaLW Olga AAALAsei oak (74A, 0641k

Tv" PN-L t() 6 ,11/4. r;a J$ Q . 1 6U1A avv-A4-Ak 1 gi- 19 88

7

It•ita,,, la een-1-

M 44

'0)g---•^--, kaii i(--- $ k

ailnONit'EALTH OF MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE

FOR OFFICE US. ONLY Full License A;,plicstion

SUPPLEMENT TO APPLICATION FOR

Pending

Approved

• FUO. 11,COSE

License

TO HE COMPLETED BY APPLICANT. PLEASE TYPE OR PRINT.

NAME:

Main L CAMPBELL

PERMANENT ADDRESS:

LOCAL MAILING ADDRESS IN (MA):

HOSPITAL:Ste-Justine Hospital

ADDRESS:

3175 COTE SAINTE-CATHERINE ,

Mnorroml

...

tinptuzr

H3T 105

Canada

YOU ARE REQUIRED TO COMPLETE THE QUESTIONS BELOW.

YES

NO

11)

  • 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 co the claim)?

i.

  • 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?

2.

  • 3. Have you ever applied for licensure or to sit for an

examination or taken an examination, under a different name?

3.

  • 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?

4.

  • 5. Have your ever failed an examination (including the FLEX

Examination) before any state or the National Boards?

5,

  • 6. Have you ever been denied a medical license, whether full,

limited or temporary, for any reason?

6.

  • 7. 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?

7.

  • 6. 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)?

8.

  • 9. Have you ever voluntarily surrendered a license to

practice medicine or any healing art?

The Board's regulations

define "disciplinary action." Please refer to 243 CMR 3.02, attached.

9.

  • 10. Have you ever withdrawn an application for medical

licensure, hospital priviledges or appointment, for any reason?

10.

  • 11. Have you ever for any reason, lost American Specialty

Board Certification?

11.

  • 12. Have you been denied required recertification by one or

more specialty boards?

If yes, which one(s)?

12.

  • 13. Have you, at any time, been a defendant in any criminal

proceeding other than minor traffic offenses?

13.

  • 14. Has your privilege to possess, dispense or prescribe

controlled substances ever been suspended, revoked, denied, restricted, surrendered or have you been called before

or warned by this state or any other jurisdiction including a federal agency at any time?

14.

  • 15. Have you ever had any emotional disturbance or mental

illness which has impaired your ability to practice medicine

or to function as a student of medicine?

IS.

  • 16. Have you ever had an organic illness which has impaired

your ability to practice medicine or to function as a student

of medicine?

16.

  • 17. Are you now, or have you been in the past, dependent upon

alcohol or drugs?

17.

  • 18. Have you ever held a license in Massachusetts or any other

state or country? If yes, list other jurisdictions.

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

4 10 :Z FM 8Z FIN SOOZ

Massachusetts Physician Renewal Application

Physician Name: ALAIN LESTER CAMPBELL

PART A

1) Current Status: Active

Renewal Due Date: 03131/2005

License No.: 60491

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.)

0

Active

El Retiring

0 Inactive

0 Do not wish to renew

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.

2a) MAILING ADDRESS

  • 9 BOSTON STREET

SUITE 9

LYNN, MA 01904-0000

El Check here to change this address

2b) HOME ADDRESS

Phone:

t

El Check here to change this address