Form Hcfd-3 - Annual Disciplinary Action Summary - 2015
ADVERTISEMENT
1
2MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE
Form HCFD-3
ANNUAL DISCIPLINARY ACTION SUMMARY – 2015
M.G.L. c. 111 § 53B requires that all health care facilities complete this annual report. M.G.L. c. 111 § 203 requires that
all nursing homes complete this annual report. The information reported in Parts I, II and IV is considered public
information. Part III is confidential. Please note that the Annual Disciplinary Action Summary Report is different
from the Annual Quality and Patient Safety Division (QPSD) Report. The Annual Disciplinary Action Summary
Report is collected by the Data Repository Unit of the Legal Division of the Board, not QPSD. Board regulations
set forth separate requirements to report certain items to QPSD.
Submission Deadline: February 2, 2016
CONFIRM BY CHECKING BOX THAT THE INFORMATION BELOW IS ACCURATE, PROVIDING ANY NECESSARY
CHANGES AND/OR ADDITIONS (LEGAL FACILITY NAME, CONTACT PERSON INFORMATION).
PART I
Legal Name of Facility:
Business Name of Facility:
Mailing Address:
Street
City/Town
State
Zip Code
Name, Phone and Position of Contact Person:
List any other facility locations, under same registration license, for which you are reporting:
________________________________________________________________________________________
PART II Report only new disciplinary actions begun on or after Jan. 1, 2015 through and including Dec. 31, 2015.
Do not include ongoing disciplinary actions that began in a prior year and continued into 2015.
Include all reportable disciplinary actions, even if you have not yet filed an Initial Report (Form HCFD-1).
If you have not filed a Form HCFD-1 on any of these actions, do so now and include it with this report.
1. DID THIS FACILITY TAKE ANY DISCIPLINARY ACTIONS AGAINST A PHYSICIAN?
No _____ If no actions were taken, please sign and date form on the bottom of page 2 and return by 1/31/2016.
Yes _____ Please continue.
2. HOW MANY PHYSICIANS DID THIS FACILITY DISCIPLINE? ___________
3. HOW MANY INITIAL REPORTS OF DISCIPLINARY ACTION WERE FILED? __________
The answers to questions #2 and #3 will be different if more than one report was filed on the same physician.
4. HOW MANY DISCIPLINARY ACTIONS WERE TAKEN IN EACH CATEGORY?
Record all actions. When two or more actions were taken against a physician, record all of the actions here.
Revocation of a right or privilege
_________
Termination/non-renewal of contract
_________
Suspension of a right or privilege
_________
Written reprimand or admonition
_________
Restriction of a right or privilege
_________
Fine
_________
Non-renewal of a right or privilege _________
Leave of absence
_________
Education/counseling/monitoring
_________
Performance of public service
_________
Withdrawal of an application
_________
Censure
_________
Denial of a right or privilege
_________
Resignation
_________
Other _________ Specify Action
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business