Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Subsequent Report printable pdf download

Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Subsequent Report

POD-2 (09/2011)

MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE

PROFESSIONAL ORGANIZATION DISCIPLINARY ACTION SUBSEQUENT REPORT

Use FORM POD-2 to report the Reversal, Modification or Completion of disciplinary actions (Part A, B or C) or the Status of

Ongoing disciplinary actions (Part D). Please type or print legibly.

• This report must be filed within 30 days of a reversal or modification of an action after appeal.

• This report must be filed within 30 days of the completion of an ongoing action.

This report must be filed every 60 days during the pendency of an ongoing disciplinary action.

•

Physician Information

Name: _______________________________________________________________

License number:____________________

Reporting Professional Organization

Organization name:____________________________________________________Telephone:______________________

Date of initial disciplinary action: _____ / _____ / _____ Date of initial report to the Board: _____ / _____ / _____

Report completed by: ________________________________________Title:_____________________________________

Signature: ___________________________________________________________ Report Date: _____ / _____ / _____

PART A. Appeal of Disciplinary Action

Complete this section when a disciplinary action is reversed on appeal.

1. Date of reversal: _____ / _____ / _____

2. Was the action reversed through an internal or external appeal (circle one)?: 1. Internal 2. External 3. Both

3. Describe the basis for the reversal:

PART B. Change in a Disciplinary Action

Complete this section when the terms of a disciplinary action have been modified in any way, becoming either more or less

restrictive, since your last report to the Board of Registration in Medicine. However, if a new action has been imposed, you

must complete and file an Initial Report regarding the new action (FORM POD-1).

1. Date of modification: _____ / _____ / _____

2. Describe the modification:

3. Describe the basis for the modification:

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Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Subsequent Report