ALAIN CAMPBELL, M.D. MASSACHUSETTS LICENSE APPLICATIONS Total As of 2015

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
I
ttiVe IC Fat
please read the instruction booklet. Copy this form and all attachments for your own record ; vou will
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.
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)
2. Other 4atne(s), if any, under which you were licensed
9 Do not wish to renew
Inactive (see instructions)
Please make corrections (type or print)
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:
PLEASE NOTE: No P.O. Box addresses for home or

business addresses.
4. a) Date of Birth:
b) Sex:
7. Cur ent American Board of Medical Specialties Certification (See Table 2)

oicode:
Code:
c) SS#:
8. Drug License Numbers. if any:

a) Federal (DEA):
b) Massachusetts:
5. a) Name of Medical School:

b) YkifffictaigEs"Y
Faculty er
MlS:
1976
6. Specialty Code(s) (See Table 1)

Coders)
Hours Der Week in Mass.
M.D.
4O
9. a) Other states where you are now licensed to practice (Abbr.)
b) States where you were previously licensed (Abbr.)
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:
.3 6/ i,"" (AP) / 0 % Facility Code:

/
(AP)
% Facility Code:
_/
/
(AP) _ %
(AP)
'N.
VAIN I YOUR L.Aalp4A1VIL:
LICtiilbt. NUMBER: tUarrii
" I'll( f L./C. I....tr
"' I -1 ---E,:- ii.n

fs .'
ay......S.)
r-.
1.E., Mintema
.d' practice insurance is covered by a) Er-Insurance Carrier
Name of Insurer:
'PRO m UTujtL 4 I
b)
Letter of Credit '
102-2-
.,
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)
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 hrstwb
5--
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
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.
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.
Registration No.: 60491
Return renewal applicatior in t BNiciaMtsfe.

Enclose check with coupon n BEIGIskrAcloas Mod
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)
0 Inactive (see below')
2. Other Name(s), if any, under which you were licensed:
El Do not wish to renew
Please make corrections (type or print)

Other Name(s):
3 A) Mailing/Home Address:
ALAIN LESTER CAMPBELL, M.D.
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
5. A) Name of Medical School:

McGill University Faculty of
Medicine
13) Year Graduated: 1976 C) Dame: MD
Specialty
Code(s) (See Table I)
6.
450
country:
..
ilSii-
Ivoiire,.: -ke.tiltss as: par c 42cet-dre....Other Address:

City/Town: _ "
_
........State: .
Zip:
"... Country:
B) Business Address:
ATLANTICARE OB/GYN
9 BOSTON STREET
EAST LYNN, MA 01904
4. A) Date of Birth:
B) SS#:
0190V-
Date of Birth: (M/D/Y):

SS#:
Sex :OM
Full Name of Medical School:
Year Graduated:
Code(s)
Degree: 0 M.D. 0 D.O.

Hours Per Week in Massachusetts
Hair Peggillatistslis and Gynecology

If OS, Print Spezia ty:
7. Current American Board of Medical Specialties Certification (See Table 2)

Code:
Code: OG
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.
0 F
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.
S (Al')
Facility Code:
% Facility Code:__ yzi e./(AP)% Facility Code:_11
41 ir (AP) gig%
Facility Code:
/
(AP)
% Facility
/
(AP)
% Facility Code:
/
(AP)
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
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
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,
16. Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine,
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?
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. 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

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

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.
Return renewal application in GREEN envelope.
Remit $250.00 for renewal fee.
Enclose check with coupon in BLUE envelope.
Registration No.:
60491
I. Activity Status:
(Check only one)
Renewal Date:
['Active
0 Inactive *(see below)
04/28/97
Corrections (type or print)

Other Name(s):
3. A) Mai ling/Home Address:
..
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
)
)
Date of Birth (M/D/Y):

Lic. Issue Date (M/D/Y):
C) Sex: 14
4. A) Date of Birth:
B) Lic. Issue Date: 10 /19/88 D) 5S14:
/
/
Sex (M/F):
55th
Full Name of Medical School:
5. A) Name of Medical School:

Medicine
C) Degree: MD
B) Year Graduated: 76
64 Obstetrics and Gynecolo
Hours Per Week in Mass.

go tor-Emu AAA &swede:*
Code(s)
6. Specialty Code(s) (See Table I)

Hours per Week in Mass.
Code(s)
OBG
Degree (MD/DO): _
Year Graduated:
a CD
If OS, Print Specialty:

Code:
Code:
OG
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 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:
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)
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:
Facility Code:___ Facility Code:_
If 999, write Neme(s):

11. My medical malpractice insurance is covered by a)
Name of Insurer:
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)
Not involved in direct/indirect patient care in Massachusetts b)
Otherwise exempt

12. Are you currently in a post-graduate training program in Mass. as a resident or clinical fellow? (check one)
13. A. What is your principal work setting? (See Table 4)
0 Yes Vigo
B. Care of patients in Massachusetts (see instruction booklet).

I) Average weekly hours involved in:
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
(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.
Signature
Date:
6z- l 2r
94

Ten West Street, 3rd Floor, Boston, Massachusetts 02111
1995.1997 Physician Registration Renewal Application
Status
Late Fee
Registration No.
Renewal Date
Fee
_60491
irmtvn $250.00 04f213/95 USA
Mailing Address:
Coriecdon of Mailing Address

Address (Mailing):
City/Pow=
State:
Country:
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:
/
/
Date of Birth (MAW):

3. Date of Birth:
Sex: M
Lic. Issue Date: 10 /19/88 SSC
Jinnut Phnnr
Corrections of Pre-Printed Information
ihntinMahigis
(617)592-3000
Home: (
/
/
Sex (WP):
SS#:
Business: (
Full Name of Medical School.
4. Name of Medical School:

Medicine
Year Graduated: 76
Year Graduated:
Degree (MD/DO):
Degree: IC
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
Code
6. Specialty Code(s) (Set Table I):

Code Hours per Week in Mess.
' OBG 64 Obstetrics and Gynecology
Hours per Week in Man.
If OS, print specialty
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:
Code:
Federal (DEA).
Mass.
INACTIVE
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 41
1'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
(AP) Facility Code:
Facility Code:
-.4.
(AP)
/ (AP)
Facility Code: _
(AP) Facility Code: /
/
(AP)
Facility Code:
(AP)
_L..=
san
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:
Facility Code: Facility Code: _
If 999, write ncune(s).
11.My medical malpractice insurance is covered by (a) Insurrace Carrier
(b) Letter of Credit
If applicable, check one,
M AList Insurer MAd cve- M N.9 -496.-1 Unclxik/a it 55
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.
(ii) Otherwise exempt:
State how 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
atbitred.
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 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?
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 waiver requested
No, training program exemption (see instruction booklet)
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
ODZZ.UUVU
I.' PHYSICIAN INFORMATION

ALAIN LESTER
First Name
CAMPBELL
Last Name
Middle Initial
Sex
Make changes to name here

First Issue Date 1.6/19/8$
Mass License fi 09.49.1

License Status Active
Hospital Affiliation
AtlantiCare Medical Center

North Shore Medical Center-Salem Hosp
Atlanticare Ob/Gyn
225 Boston St,Suite 205
Lynn, MA 01904
U.S.A.
(617) 592-3000
Make address eu,reciions here: z. A

LAN I I eith, oSibl
1.114N
Make any corrections to above here-
05.17.00
M.o.t 4 0
C61.1/ 5-ci
3.00.
Insurance Plan Affiliation:
Licenses fkid in Other States:
Fit -Bic Es
AttikvaRia
ift.g.whutaff fr y tuf.o,tf
.17f.o1.Mattetink.s.kattcAlb
Accepting New Patients? %yes No

Accept Medicaid?
[Wes ETI No
(Please correct as necessary)

II. EDUCATION & TRAINING
McGill University Faculty of Medicine
IlidicaSehool
76
Date
MD
Degree
Make corrections here

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Stan
Residency Programs)
14.2 fir,
stbspagsail rr itornitiAL Csoetm. vugesesk( -v.ge4041 lltnisafet.) ji-eseiretc 4vtC qq-Start

Residency Program(s)
Potvinal of
lierscebilo
Residency Program(s)
III. SPECIALTY
End.iast 4-7
End --)U Non
20--turnivg, ItesP-Thttlisiti (tAnPA Nivcy In End 411168-0

Start
Primary Specialty: Obstetrics and Gynecology
BOARD CERTIFICATION
Certifying Board Name: Board of Obstetrics and Gynecology
Secondary Specialty:
Certifying Board Name:
Make any corrections here:
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)
DiQciplinary Action
Date
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
Date
Date
Date
Date
Date
Amount Paid 0.0000

Amount Paid
Amount Paid
Amount Paid
Amount Paid
Amount Paid
Basis for Complaint

Basis for Complaint
Basis for Complaint
Basis for Complaint
Basis for Complaint
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.
(q12
Awards, Honors
trobEarsitip, No-om tt Astifecil etypiert
Publications
oremibM
R Estfit2t 14 8 ufittg Mc 6/a. titaveheSity

Ve...bita3/4 iv Lo41/0
4
let% M Sc. dig/S-6 keit* stoat
D:A MtGt41UN14.ERsrrr
14
Note: Please return the survey In the enclosed envelope to:
Atlantic Associates, Inc., 8030 South Willow Street, Manchester, NH 03103

Physician Profile

1993-1995 Physician Registration Renewal Application
Registration No.
60491
Status
Fee
ACTIVE $250.00
Renewal Date
04/26/93
Late Fee
$25.00
Correction of Mailing Address:

Address (Mailing):
Mai ling
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.
Corrections of Pre-Printed Information
1. Other name(s), if any, under which you were licensed:

Name:
Address (Home).
City/Town:
State:
Country Code:
Address (Business):
City/Tovm:
Country Code'
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:
Date of Birth (M/D/Y)

Telephone Number.
Home: ( )
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: (
Full Name of Medical School.
i1c3ill University Faculty o f

Medicine
Year Graduated: 7 6
Year Graduated:
Degree (MD/DO):
Degree: M
5. a) Other states where you are now licensed to practice (Abby):

b) States where you previously were licensed to practice (Abbr.):
t
Code
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 (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):
No, waiver requested

9. 1 have completed my CME requirements in the two years preceding my renewal date: Yes
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:
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')
If 999, print natne(s).

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:
Facility Cale: Facility Code:
Facility Code:
_
IM11.1,
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

1991-1993 Physician Registration Renewal Application
Registration No.
Status
Fee
Renewal Date
For Of Use Only

M.R.
Pr.
Bk.
Ch.
D.E.
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.
Corrections of PrsPrinted Information
1. Other Name(s), if any, under which you ware licensed:
Name:
2..e) Address (Home):
Address:
City/Town
State:
Country Code:
Address:
Cityfrovm:
State:
Country Code:
2.12) Address ((Business):
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
Data of Birth (M/D/10:

Lb. Issue Date(M/D/Y):
&sines
( 17)592-3000
Home: (___)
Sex (WF):
T_____/
/
SSN il:
Telephone Number:
1391110
4. Medical Sthool Code: QU0 01Year Graduated: 7 6 Degree:

Name of School:
ID
Business: (
School Code:
if 99999, write School.
Year Graduated:
Degree (MD/DO):
Faculty of Medicine. McGill Univer it

5, a) Other States where you are now licensed to practice (Abby):
no 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
03G
0 Obstetrics ana Gyneco I. o ) y

0
Hours her
gOi
In Mass
____ _.......
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 Gynecology
Coda:
8. Drug License Number(s) (if any) (optional]: a) Federal (DEA)_

c) State (MA) DM_
D.
Code:
Code:
b) How many DEA nos. do you have? 1
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:
/_ )
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
. If applicable, check one.
UM Insurer: MED. MALP. JOINT UNDERW. ASS., MA.

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;
_
(II) OTHERWISE EXEMPT;
Mate how otherwise exam*
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.
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?
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
5150.00 must accompany APPLICATION No currency or personal checks)
vo X
For Office Use
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.
Place of Birth St-Hyac inthe ,
Quebec, Can a d a
H3R 2T6
PreMedical Education
Medical Education
School University of Montreal

Years Attended
McGill University
School
B.Sc. : 1969-72
us Attended
previonely, B A. (Univ. Mt1, 1969) e
1972-76 M.11
Postgraduate Educatiou Moattital AMmiadataata

Position
Place
?DST CR A.DIIATI EDUCATTONi
C.M.
Dater
14_,Sc (Ex50111nVRI vMelNine - Endocrinology)
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
Other names under which you have been licensed'
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),
Piv.a.tie, & CertilLAZ-MgAZIi)
504, Se0+444: esgart

min
D6/(Y$
tt
1-aAkm.
(
kg- &PAR.
14 k`iialLela3/4 Jr:clumutok &aa. CA-at 616113
4124,0*g%'" AvjL
aA
1.144:
al-
f r1983
4 1:ATirs4SAI
(
-A
-)Ci"
4C,_ AA 16 .
OUX
41"
te"le C'OYIONWIALTH OF MASSACHUSETTS
mr
BOARD OF REGISTRATION IN MEDICINE

SUPPLEMENT TO APPLICATION FOR
FUEL .LICENSE
FOR OFFICE US' ',SLY

Full License Application
Approved
Pending
License 0
TO BE COMPLETED BY APPLICANT. PLEASE TYPE OR PRINT.

NAME: Alain L. CAMPHEit
HOSPITAL: Ste-Justine Hospital
PERMANENT ADDRESS: ADDRESS: 3175 COTE SAINTE-CATHERINE,
LOCAL MAILING
Canada .
Mnntrpal
ADDRESS IN (MA):
IC5
H31.
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)?
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
12.
more specialty boards?
If yes, which one(s)?
13. Have you, at any time, been a defendant in any criminal
13.
proceeding other than minor traffic offenses?
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
14.
a federal agency at any time?
15. Have you ever had any emotional disturbance or mental
illness which has impaired your ability to practice medicine
15.
or to function as a student of medicine?
16. Have you ever had an organic illness which has impaired
your ability to practice medicine or to function as a student
16.
of medicine?
17. Are you now, or have you been in the past, dependent upon
17.
alcohol or drugs?
18. Have you ever held a license in Massachusetts or any other
state or country? If yea, list other jurisdictions.
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

1969-1991 Physician Registration Renewal Application, Paget of 2
008264 41Zf
Beard Use Salo:

Registration No.
6 0491
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
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.
CAMPBELL
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):
2.b) Address (Home):
SAME AS ABOVE
2. c) &Wrest) (Business):
ATLANTICARE OB/ GIN

LYNN. MA . OL9 oq
495 NESTPRN AVF

2.di Telephone (Busirtem): (6 1 L.)
6. a) Medical School Code (See Table 1): Q0001

6. b) Year Graduated: 1 97 6
5. Soar) Security No. (Optionaipt
4. Sex: MALE) FEMALE
3.Date of Birth (140/DA/YR):_
6.0) Country: U.S.
2 a) Telephone (Home) (Optional):
5 9 2- 3 0 00 _ Extension
tr agog, write Name:
60) Degree: M.D.XX
D.O.
1199g, write Name:
Canada X Coda If Other (See Table 2):
7. Work Setting (Circle end indicate Peroent(%)of Practice TMs):

10 Hospital
15 Private Office
30 Mental Health Canter
25 Clinic
202F'
45 Educational Institution
40 HMO Facility
55 Government Facility
60 Plant/ComMerolal Setting
a Professional ActMly (Circe and Indicate Percent(%) of Professional Time):

10 Resident or Fellow
20 Practice Involving Direct Patient Care
30 Administrative Activities
40 Medical Teaching
99 Other
50 Medical Research
10 %
9. SpeoWty Code (See
TOM 3): jab G Percent of Practice Time: too
20 Partnership/Group Practice
35 Nursing Home
50 Medical Society
99 Other
10
a
a
8. b) Mora. Lie Issue Date

90
(see Boar wail enlaces.)

(MO /DA/YR):1I 19/ 88
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
Board of Allergy & Immunology

Board of Anesthesiology
Board of Colon & Rectal Surgery
Board of Dermatology
Board of Emergency Medicine
Board of Family Rectos
Board of Internal Medicine
Board of Neurologloal Surgery
OP
OS
OT
PA
PE
PMR
10. bid YES, circle which &midis):

PS
Board of Nude.? Medicine
PM
Board of Obstetrics & Gynecology
Board of Ophthalmology
PN
Board of Orthopedic Surgery
Board at Otolaryngology
S
Board of Pelhobov
TS
Board of Pediatrics
Board of Physical Medicine & Rehabilitation
Board of Plastic Surgery

Board of Preventive Medicine
Board of Psychiatry & Neurology
Board of Radiology
Board of Surgery
Board of Thoracic Surgery

Board of Urology
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
11 999, write Name(s):

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.
(See Table 4.)
998
Facility Cods,
Fact Ay Code: _ Fealty Code: _
Fealty Code:___
Facility Code
11999, write Ns11114): q Qk
kit NI BEM: S13- - 1/41.15 TUVE'
tut 04.44 Ain't
Was PI rof-t.
n/ ties in tot.
LiN ttra 5 Ity
-%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:
P./ Rhine saw
3 *hotbed clot(-le true.

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:
Registration No.. 6 0 4 9 1
ra MPPFTi
12. 41) Other States where you are now Awned to practice (Abbreviate):
QU
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
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
AMERICAN SPECIALTY BOARD
FOR OFFICE USE ONLY

Specialty License Application
Pending
Approved
License #
TO BE COMPLETED BY APPLICANT. PLEASE TYPE OR PRINT.
CA
NAME:
PERMANENT ADDRESS:
MP 8 L a_
ALAI
HOSPITAL
ADDRESS:
C44-- L
( e_
LOCAL MAIUNG:
Applying on the basis of which

approved American Specialty Board?
ADDRESS IN (MA);
6 a /4. Ai
Certificate Category?
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
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;
For Office Use
*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
Dalt March 11 th , 1988.
Lau
Place of Birth St-Hyacinthe, Quebec, Ca ada
School
Date of Issuer 91)L'

/
School
B.Sc. : 1969-72
B A. (.Univ. Mtl, 1969
iceilIS
McGill University
A t tended 1972 -
76
Postgraduate Educed** & Hospital Appointee/ad

Position
Place
M.D
C.M.
Dates
- Endocrinology)
POSTGRADHATE EDU_CATIO_N: M.Sc.
Renirinn_cy programs_ OB/GY.N: McGill Univ. and Univ. Mtl; 1977-80

Appointments: Assistant Prof Clinical OB/GYN , rac Medicine anti
u les,
ra uate
List all other states in which you have been fully licensed.
university Hospitals; 1981-actual 1p88;
QUEBEC, only, Canada; 77-182
Other names under which you have been licensed:
none
List Specialty Boards by which you are certified. AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY
1. ackz:tte ifitAAA. 4.i-_14,, L . m , c.. c . at, 1/4 t. x .v- ;

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atuve -,A, tkokilaLegaLW Olga AAALAsei oak (74A, 0641k
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7 Itita,,, la een-1'0)g---^--,kaii i(--- $ k
ailnONit'EALTH OF MASSACHUSETTS
FUO. 11,COSE
FOR OFFICE US. ONLY

Full License A;,plicstion
Pending
Approved
License
TO HE COMPLETED BY APPLICANT. PLEASE TYPE OR PRINT.

HOSPITAL:Ste-Justine
NAME: Main L CAMPBELL
PERMANENT ADDRESS:
ADDRESS:
LOCAL MAILING
ADDRESS IN (MA):
Hospital
3175 COTE SAINTE-CATHERINE ,

Mnorroml ...tinptuzr
Canada
H3T 105

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)?
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 your ever failed an examination (including the FLEX
Examination) before any state or the National Boards?
6. Have you ever been denied a medical license, whether full,
limited or temporary, for any reason?
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?
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)?
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.
10. Have you ever withdrawn an application for medical
licensure, hospital priviledges or appointment, for any reason?
11. Have you ever for any reason, lost American Specialty
Board Certification?
12. Have you been denied required recertification by one or
more specialty boards?
If yes, which one(s)?
13. Have you, at any time, been a defendant in any criminal
proceeding other than minor traffic offenses?
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?
15. Have you ever had any emotional disturbance or mental
illness which has impaired your ability to practice medicine
16. Have you ever had an organic illness which has impaired
your ability to practice medicine or to function as a student
of medicine?
17. Are you now, or have you been in the past, dependent upon
alcohol or drugs?
18. Have you ever held a license in Massachusetts or any other
state or country? If yes, list other jurisdictions.
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)
Massachusetts Physician Renewal Application

Physician Name: ALAIN LESTER CAMPBELL
License No.: 60491
PART A
Birth Date:
Renewal Due Date: 03131/2005
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.)
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: (
Home address cannot be a Post Office Box
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:
2c) BUSINESS ADDRESS

9 BOSTON STREET
SUITE 9
LYNN, MA 01904-0000
10 :ZFM 8Z FIN SOOZ
El Check here to change this address
Business address cannot be a Post Office Box
kor U At <A$a, 4-7 6 r-fiC'C
1-2 i . STI2- 96.5
5) Specialties (See Renewal instructions, page 9.)
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.)
Update General Certificates and Subspecialty Certificates

below. Please add additional Certifications as required.
List Certifying Board(s) below:

I
Board Name
ABMS or AOA
0
Certificate/Subspecialty
Correct?
Delete?
Obstetrics & Gynecology
MIERI410 ba010 blisitches Oltutc204#

0
0
0
s
0
0
0
0
0
Page 1 of 5

License No.: 60491
Please make corrections as necessary
(See Renewal Instructions, page 4)

7) Drug License Numbers, if any:
8a) Other states where you are now licensed to practice (Abbr.)
MN'S
a) Massachusetts:
8b) States where you were previously licensed (Abbr.)
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
North Shore Medical Center - Salem Hospital
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
12) Medical Liability Insurance Information (See Renewal Instructions, page 5)

My medical liability insurance is provided through: (check one)
is Insurance Carrier (complete below)

Current Insbrance Carrier: ProMutual Group /Policy dates:
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
Government Employee Federal Tort Claims Act (FTCA)
Oth'erwise exempt (Please explain):

License No.: 60491
13) Do you perforth any surgery in your office? (See Renewal Instructions, page 5.)
Yes
No
If Yes, please complete Form PCA-O "Office Based Surgery"
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?
22) CME CERTIFICATION:

a) Have you completed your CME requirements preceding your renewal date?
(ayes No
b) If no, are you requesting a CME, waiver?

Check to request CME. Waiver. A CME waiver request form must be submitted at least 30 days prior to
your license expiration date. (See Renewal Instructions, page 8)
c) If you are exempt from CME requirements, check reason for exemption. (See Renewal Instructions, page R.)
CME. EXEMPTION: (check one)

Page 3 of 5
Inactive Status
Residency/Fellowship training

License No.: 60491
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
Commonwealth of Massachusetts Board of Registration in Medici

560 Harrison Avenue, Suite #G-4, Boston, MA 02118 (617) 654-9810 http://www.massmed
rd.org

ig
Before proceeding, please read the instruction

need copies for credentialing and other purpose
green envelope at least 4 weeks before your rene
chments for your own records; you will

44414 a d al
attachments must be returned in the
is complettAl ironic& ori
e.
APR 1 1
?Burn fie al application in GREEN envelope.
-Remit $400.00 for renewal fee (non-refua ab
Enclose ch
with coupon In BLUE envelope.
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
Renewal Date: 04/28/2003
Registration No.:60491
0 Active
0 Inactive (see instructions)
(Check only one)

0 Other Name(s) 0 Name Change (enter name below
A) Mailing/Business Address:
3.
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:
b) Sex:
M
c) SS#:
_McGill University Faculty nf Medicine

b) Year Graduated: 1976 c) oegres: 3),
Code(s)
0
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

Code:
Code:
8.Drug License Nuggets, if any:
a) Federal (DEA):
b) Massachusetts:
9. a) Other states where you are now licensed to practice (Abbr.) Aid it/ E
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:_ _/
/
/
_ (Al')
(AP)
cal
eta
CR licik Pete
PRINT YOUR LAST NAME:
tt-
LICENSE NUMBER:
11. My medical malpractice insurance is covered by Enn.surance Carrier

Insurer's name. (Required):
vra
- 3/0 2. Z
6ofqi
0 Letter of Credit
Policy dates: From: 02 /0-7-/ 193 To:
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
C hrs/wk B) outpatient 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,
16. Has any lawsuit, other than a medi !malpractice suit, which is related to your competency to practice medicine,
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
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.
PME EXEMPTION: Check one:
Inactive status
Residency/Fellowship training (See instructions).
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
MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING.
Commonwealth of Massachusetts Board of Registration in Medici
560 Harrison Avenue, Suite #G-4, Boston, MA 02118 (617) 654-9810 http://www.massmedlio"ard.org

gcurnmerea-reneverren
44isfirokeii a i RIM
Before proceeding, please read the instruction

need copies for credentialing and other purpose
green envelope pt least 4 weeks before your rene
chments for your own records; you will

attachments must be returned in the
e.
API) I I
'Remit $400.00 for renewal fee (non-refut

e al application in GREEN envelope.

20urn
Emilia chei with coupon In BLUE envelope.
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
Renewal Date: 04/28/2003
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
0 Inactive (see instructions)

3.

0 Other Name(s) 0 Name Change (enter name below
A) Mailing/Business Address:
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:
b) Sex:
M
c) SS#:
b
ylgallasrai;sity Faculty Bf Medicine
e
1976 ci greM.D.
Codes)
Hours per Week in Mass. 35
OBG

Code:
Code:
8.Drug License Numbers, if any:
a) Federal (DEA):
b) Massachusetts:
9. a) Other states where you are now licensed to practice (Abbr.) Am Ai
(32.11,
.)
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:_
/
(AP)
(AP)
%
%
PRINT YOUR LAST NAME:
efim f P> E Li-
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,
16. Has any lawsuit, other than a medicat malpractice suit, which is related to your competency to practice medicine,
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
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?
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
Physician Renewal Application
Physician Name: Alain Lester Campbell, M D
License No.: 60491
Current Status: Active
License Expiration Date: 4/28/2011
1) Activity Status: Active

2) Address & Contact Information
Mailing Address:
Cardone & Asso Rep Med, 2 Main St

Suite 150
Stoneham
Massachusetts - 02180
United States of America
Home Address:
Business Address:
2 MAIN ST, CARDONE & associates rep med

Suite 150
Stoneham
(781) 592-3000
3) Email Address:
4) Fax Number: (781) 438-9601
5) Specialties
6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Information
ABMS/AOA Board Name
ABMS
Certification
Subspecialty
7) Drug License Numbers

Massachusetts
Federal IDEA)
Federal (DEA) XS
8) Other states where you are now licensed to practice

New Hampshire
9) States where you were previously licensed
None Reported
10) Work Sites
List of all work sites in Massachusetts, including health care facilities (where you are credentialed), private
office, clinics, nursing homes, etc
WorkSite
Page 1 of 5
Location
None Reported
Date: 4/26/2011
Time: 11:17 AM
License No.: 60491
Physician Name: Alain Lester Campbell, M.D.
11) Care of patients in Massachusetts

Average weekly hours involved in:
a) inpatient care 0 hrs/wk

b) outpatient care 10 hrs/wk
12) Medical Liability Insurance Information

Insurance Carrier
Medical Professional Mutual Ins Co
Policy Start Date

02/07/2011
Policy End Date

02/07/2012
Policy Type
Occurrence Policy
13) Do you perform any surgery in your Massachusetts office?

14) Claims Made
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?
b)Pending: Are there any unresolved malpractice claims against you today, i.e., any claims that have not
been resolved, settled or adjudicated during this time period?
15) Claims Closed
16) Other Civil Lawsuits
a) New: Have there been any claims, other than medical malpractice claims, filed against you during this
time period?
claims, during this period?
17) Criminal Charges
a) Have you been charged with any criminal offense during this 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 Application of Issuance of Process pending against you?
18) Other Issues
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?
Page 2 of 5
Date: 4/26/2011
Time: 11:17 AM
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
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
License No.: 60491
Compliance with Legal Responsibilities

Online profile:
pg 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.
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
License No.: 60491

Mailing Address:

Suite 150
Stoneham
Home Address:
Business Address:

Suite 150
Stoneham
(781) 592-3000
3) Email Address:
4) Fax Number: (781) 438-9601
5) Specialties
Information
ABMS/AOA Board Name
ABMS
Massarhimatts
Certification
Federal IDEAI
Subspecialty
Federal (DEA) XS

New Hampshire
None Reported
10) Work Sites
WorkSite
Page 1 of 5
Location
None Reported
Date: 4/30/2013
liras: 12:37 PM
License No.: 60491

Average weekly hours involved in: a) inpatient care 0 hrs/wk
b) outpatient care 1 hrs/wk
I am not required to have malpractice insurance.
Other
Lymphoma Chemo Dec Jun 2012 comp including 3 hops Sept. Dec. many days IV abx. Adm
asthma Dec, severe neutropenia Ap 23 170 ANC No patient since chemo no wish to retire insurance
costly; take when stable Inactive lic long to re-establish.

14) Claims Made
b) Pending: Are there any unresolved malpractice claims against you today, i.e., any claims that have not
15) Claims Closed
time period?
18) Other Issues
c) Have you been the subject of an investigation by any governmental authority, including the
Massachusetts Board of Registration in Medicine or any other state medical board, health care facility,
group practice, employer or professional association?
cl,) Have you been the subject of a disciplinary action taken by any governmental authority, health care
Page 2 of 5
Date: 4/30/2013
Time: 12:37 PM
License No.: 60491
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
License No.: 60491
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
practice medicine?
Page 4 of 5
Date: 4/30/2013
Time: 12:37 PM
Online profile:
License No.: 60491
I have reviewed my Physician Profile and confirm that the information is accurate.
pursuant to M.G.L. c. 112 sec. 5F, when i have a reasonable basis to believe that a person violated any
beneficiaries in accordance with the Medicare fee schedule, pursuant to M.G.L. c. 112 sec. 2.
pursuant to M.G.L c. 112 sec. 12AA.
as a physician.
El
I have reviewed the above statements and certify that I understand my requirement to comply with
El
Page 5 of 5
Date: 4/30/2013
Time: 12:37 PM
Data bnse Number: 60491
Dr. Alain Lester Campbell
NATIONAL PROVIDER IDENTIFIER (NPI)

The primary purpose of the NPI is to uniquely identify health care providers as "health care providers" in H1PAA standard transactions.
The NPI 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 H1PAA NPI 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 NP1 directly by using the NPPES web
site at wwvv.NPPES.cms,hhs.aov.
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 bekm. supply appropriate information, and stem the bottom of the page.
My current NPI is:
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)
(follow instructions for Option 3)
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:
E11:11/Iv LIEGE] Qix

DEJI I ElE1110
OD I DODO I
Taxonomy Description (Print)
0 bg rf-Tret es 4
a',ovtcotta y
NPI REOUIRED INFORMATION

In an ongoing effort to improve the quality of the information we collect, please review the following information and make corrections
as necessary. Please note: This information is required if you authorize BORIM to apply for an NP1 on your behalf.
Social Security Number:
State of Birth (if US):
Country of Birth (if outside the US): CACW1.1> il
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
Dr. Alain Lester Campbell

9 Boston Street
Suite 9
Lynn, MA 01904-0000
iLtibknSe Board of Registration in Medicine

1561) Harrison Avenue, Suite G-4
Boston, MA 02118
617-654-9810
www.massmedboard.org
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,
Martin C. Crane, M.D.

Board Chair
PLEASE COMPLETE NPI FORM ON THE BACK OF THIS LETTER AND RETURN TO
THE BOARD IN THE GREEN ENVELOPE. PLEASE REMEMBER TO SIGN AND DATE
THE FORM BEFORE MAILING. THANK YOU

License No.: 60491
PART A
Renewal Due Date: 03/31/2007
Birth Date
Check only one: (See Renewal Instructions, page 3.)
Retiring
Active
Inactive
Do not wish to renew
Business addresses CANNOT be a Post Office Box.
2a) MAILING ADDRESS
9 Boston Street
Suite 9
Lynn, MA 01904-0000
Mailing Address:
APR I 0 2007
City/Town:
Zip:
State:
Country:
Check here to change this address
2b) HOME ADDRESS
Home Address:
City/Town:
Zip:
State:
Country:
Home Telephone:(
Phone:

9 Boston Street
Suite 9
Lynn, MA 01904-0000
Business Address:
City/Town:
Zip:
State:
Country:
Phone: (781)592-3000
correct your E-maiLaod Fax Number below:

3) E-mail Address:
4) Fax Number:
781-592-9625
5) Specialties (See Renewal Instructions, page 4)
Delete?
List Additional Specialties:
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 Boa rd(s) below:

Board Name
Certificate/Subspecialty
Delete?

in
ABMS or AOA
ABMS
0
0
0
Page 1 of

Physician Name: Main Lester Campbell, M.D.
License No.: 60491
(See Renewal Instructions, page 4.)


Corrections:
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
11) Care of patients in Massachusetts (See Renewal Instructions, page 4.)

b) outpatient care
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.
0 Claims made with tail coverage
Type of Policy:
I Occurrence Policy
(Enclose a copy of the certificate of insurance or the face sheet)
o Letter of Credit subject to Board approval (Attach a copy.)

0 I am registering with Active status but I am not required to have medical liability insurance because I am:
Check one:
0 Not involved with direct or indirect patient care in Massachusetts
A Government Employee under Federal Tort Claims Act (FTCA)
Otherwise exempt (Please explain)
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

License No.: 60491
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
a) New: Have there been any claims, other than medical malpractice claims, filed against you during
this time period?
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,
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?
21) Has any medical liability insurance carrier restricted, limited. terminated, imposed a surcharge or
have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by
a medical liability insurance carrier?
is Yes
No
b) If no, are you requesting a CME waiver?
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
1.1

License No.: 60491
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
Massachusetts Board of Registration in Medicine

560 Harrison Avenue, Suite G-4
Boston, MA 02118
617-654-9810
www.massmedboard.org
Ur
r.11'
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,
Martin C. Crane. M.D.

Board Chair
Please complete the NPI form on the following page.
Page 6 of 9

License No.: 60491

r:u
NATIONAL PROVIDER IDENTIFIER (NPI)
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.
fitdMy current NPI is:
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):
(follow instructions for Option 3)
By checking this option and signing the bottom of this page, I hereby authorize the Board to apply for an NPI on my behalf.
As an inactive physician, I do not wish to obtain an NPI.

HIPAA TAXONOMY CODES
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
Taxonomy Description (Print)
dencoces- cyiacetiti
NPI REQUIRED INFORMATION

In an ongoing effort to improve the quality of the information we collect, please review the following information and make corrections
as necessary. Please note: This information is required if you authorize BORIM to apply for an NPI on your behalf.
Social Security Number:
State of Birth (if US):
Gender: f& Male
Country of Binh (if outside the US):
CANA*
0 Female
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: idl I authorize 0 I do not authorize the Board of Registration in Medicine to provide my NPI number to any
authorized hospital, health plan, or health organization.
Please sign and date to confirm tha a f the inf rmation on this form is true and accurate.
Signature:
Page 7 of 9
Date: 4::9l; 417/1 49
17---

Physician Name: Main Later Campbell, M.D.
License No.: 60491
PART A
Birth Date:
Renewal Due Date: 03/31/2009
Check only one: (See Renewal Instructions, page 3.)
0 Inactive
0 Retiring
0 Active
Business addresses CANNOT be a Post Office Box.
2a) MAILING ADDRESS
9 Boston Street
Mailing Address:
Suite 9
State:
City/Town:
Lyon, MA 01904-0000
County:
Zip:
2b) HOME ADDRESS
Home Address:
State:
City/Town:
Country:
Zip:
Phone:
El Check here to change this fres:
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:
Phone: (781)592-3000

Comet Your Email and Fax Number below:
3) E-mail Address:
4) Fax Number:
781-592-9625
5) Specialties (See Renewal Instructions, page 4)
Delete?
List Additional Specialties:
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

ABMS or AOA Certificate/Subspecialty

ABMS
Delete?
0
0
0
0
Page 1 of 7
Co
co
(.0

(See Renewal Instructions, page 4.)
a) Massachusetts:
b) Federal (DEA):
License No.: 60491

Corrections:
AW
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)
List the names of all work sites in Massachusetts
(See above and description on page 4.)
State
Delete?
Union Hospital
.
0
0
iii
11) Care of patients in Massachusetts (See Renewal Instructions, page 4)

b) outpatient care
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:
0 Not involved with direct or indirect patient care in Massachusetts

A Government Employee under Federal Tort Claims Act (FICA)
Otherwise exempt (Please explain)
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

License No.: 60491
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
Renewal Instructions for additional information and definitions.

YES NO
Co
14) CLAIMS MADE

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

a) New: Have there been any claims, other than medical malpractice claims, filed against you during
this time period?
d) Are any Applications for Issuance of Process pending against you?
18) INVESTIGATIONS AND DISCIPLINARY ACTIONS

a) Have you withdrawn an application to any governmental authority, health care facility, group practice,
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?
21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge or
nse to an inquiry by
have you voluntarily restricted, limited or terminated your insurance coverage in i
a medical liability insurance carrier?

b) If no, are you requesting a CME waiver?
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

License No.: 60491
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
understand the punishment for failure to comply.

2) I certify that I 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.
Ql
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.19A, sec. 15, and I understand the punishment for failure to comply.
4) I certify that I have complied with my obligations to report the treatment of wounds, burns and other injuries pursuant to G.L. c. 112,
sec. 12A.
5)1 certify that 1 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. I I2, sec. 5F,
when I have 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 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) 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, sec. 49A, my license shall not be issued or renewed unless I make these certifications under penalties of
FedurY.
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 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 the Patient Care Assessment Regulations, 243 C.M.R. 3.00 et seq. 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) 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.
Check One:
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
License No.: 60491

Mailing Address:

Suite 150
Stoneham
Home Address:
Business Address:

Suite 150
Stoneham
(781) 438-9600
3) Email Address:
4) Fax Number: (781) 438-9601
5) Specialties
Information
Subspecialty
Certification
ABMS/A0A Board Name
None Reported
Massachusetts
Federal (DEA) XS
Federal (DEA)

New Hampshire
None Reported
10) Work Sites
WorkSite
North Shore Medical Center-Union Hosp
Page 1 of 6
Location
Date: 4/28/2015
lime: 5:54 PM
License No.: 60491

Average weekly hours involved in: a) inpatient care 0 hrs/wk
b) outpatient care 0 hrslwk
I am not required to have malpractice insurance.
Other
Health chemo,stage4 CLUSLL, exper drug stage 1, Dec 2011 to June very slow marrow recovery,
multiples hospitalizations, 1st N WBC, Dec 2014, 2nd Feb 2015. Assess stability desire to return.
Renew-decide. Board certif expired,written exam to take

14) Claims Made
b)Pending: Are there any unresolved malpractice claims against you today, i.e., any claims that have not
15) Claims Closed
time period?
18) Other Issues
b) Have you taken a leave of absence from any health care facility, group practice or employer for
reasons related to your competence to practice medicine?
c) Have you been the subject of an investigation by any governmental authority, including the
Massachusetts Board of Registration in Medicine or any other state medical board, health care facility,
group practice, employer or professional association?
Page 2 of 6
Date: 4/28/2015
Time: 5:54 PM
License No.: 60491
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
Physician Name: Alain Lester Campbell, M.O.
License No.: 60491
medicine?
practice medicine?
Page 4 of 6
Date: 4/28/2015
lime: 5:54 PM
License No.: 60491
25) Electronic Health Records Proficiency

I have demonstrated proficiency in the use of EHR by completion of 3 hours of a Category 1
EHR-related CPD course that discusses, at a minimum, the core and menu objectives and the Clinical
Quality Measures for Meaningful Use.
26) Requirement to Complete Training in Recognizing and Reporting Child Abuse
Have you completed training to recognize and report suspected child abuse or neglect?
Page 5 of 6
Date: 4/28/2015
lime: 5:54 PM
License No.: 60491

Online profile:
I have reviewed my Physician Profile and confirm that the information is accurate.
pursuant to M.G.L. c. 112 sec. 5F, when I have a reasonable basis to believe that a person violated any
beneficiaries in accordance wit-i the Medicare fee schedule, pursuant to M.G.L. c. 112 sec. 2.
pursuant to M.G.L c. 112 sec. 12AA.
as a physician.
El
I have reviewed the above statements and certify that I understand my requirement to comply with
El
Page 6 of 6
Date: 4/28/2015
Time: 5:54 PM

560 Harrison Avenue, G-4
Boston, Massachusetts 02118
(617) 654-9800
Enforcement Division Fax: (617) 451-9568
Legal Division Fax: (617) 357-8453
Licensing Division Fax: (817) 428-8358
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
Visit Our Website At: httpdAvww.masamedeoard.org

Boston, Massachusetts '02118
(617) 654-9800
Enforcement Division Far (617) 451-9568
November 8, 2002
Re:
Main Campbell, M.D.

Docket No: 02-179
The Complaint Committee of the Board of Registration in Medicine met on November 6,

2002 and carefully considered the information you fUrnished regarding your complaint. Your
complaint, the physician's response, and the medical records were thoroughly reviewed.
The Committee has decided to close this docketed complaint
. Additionally, the Committee wants you to know that these
documents have been placed in this physician's permanent record.
The Committee members appreciate your efforts in bringing this matter to their attention.
If you have any questions please feel free to contact meat (617) 654-9891.
Patricia Cufran Godson

Clinical Care Reviewer
Enclosure
13AOCU1SHAREM ETTFR8101141:141,44NT
oar! 1)!M r dfrn\AAA.Faudattrr4er
Visit Our Website Al: http://www.masamedboard.org
CO
0
'
6
July 18, 2002
Ms Luz A. Carrion
Paralegal, Clinical Care Unit
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,
A,(impleaMain L Campbell, MD, MSc, Diplomate ABOG (1986, recertified 1996)

References:
1- Andrews WW, Leveno KJ, Sherman ML et al: Elective hospitalization in the
management of twin pregnancies. Obstet Gynecol 77:826, 1991
2- Kemppaineu AS, Karjalainen 0, Ylostalo P, et at Ultrasound screening and
perinatal mortality: Controlled trial of systemic one-stage screening in pregnancy.
Lancet 336:387, 1990
3- Kovacs BW, Kirschbatim TB, Paul Rif: Twin gestations, I. Antenatal care and
complications. Obstet Gynecol 74:313, 1989
4- Jeanty P: fetal biometry. In Fleischer AC, Romero R, Manninf FA, loamy PJ,
James AE (eds): The principles and Practice of Ultrasonography in Obstetrics and
Gynecology, 4 ed. Norwalk, CT, Appleton & Lange, 1991, p 93
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
Patient Name (if different)
Ends.
amt,_
Street Address
Cl
BusinersiDaythne Phone
Mailing Address (if different)

State
Zip Code
Home Phone
Compland agdast
Acupwidurist
(For complaints against Chiropractors, Dentists, Names, Optometrists, Podiatrists or Psychologists, please
contact the Division of Registration at (817)727-7498. or 298 Causeway St., Boston. MA 0211(1
This complaint cannot be processed wRhout the fill name of the physician or acupuncturist. Please verify spelling.
Full Name wa & Last) of Physician a Aaspunatalst (one name per form) Photocopies are acceptable.
Aki% \ earn ckei.

ct &new\ St. t iitA (mosZip Code
t- Sci a - s6Qa
Bitsittenenot;ve. Atecriea ove oc
Name and Location of Health Care Facility Of
Address
Nature of Complaint
CI
Substandard Medical Care

O
Drug Dealing
Professional Misconduct
O
(k1111111111 Conviction
CI
Sexual Misconduct
O
Patient Neglectittbandamnent
0
Rude or Discorrteous Behavior
O
Unlawful Disaimhsation
O
Impaired by Alcohol or Drugs
0
Mang for Services Not Rendered
O
Impaled by Mental or Emotional Illness 0
Failure to Supervise Staff
O
Failure to Provide Medical Records
0
False Advertising
Oor
verdo:le
Medical Records
Fraud
%THEE et f ener0
, rwrys
nr. A r
k Cri1/4S0)..CY:\
iti
Failure to complete and sign this release may prevent Investigadon of your complaint.
Release of Medical Records and Information

Patient Name: _
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.
I FURTHER AUTHORIZE MY MENTAL HEALTH PROVIDER(S) TO DISCUSS EVALUATIONS,

DIAGNOSES OR TREATMENT AND/OR RELEASE ANY AND ALL OF MY MEDICAL RECORDS TO THE
MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE. THIS AUTHORIZATION REPRESENTS A
WAIVER OF THE PSYCHOTHERAPIST-PATIENT PRIVILEGE, AS DESCRIBED IN O.L. c. 233,5 20B.
Signature of Patient. _
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.
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Attach copies of related donut,* to
The information in this complaint is true, correct and complete to the best of my Immykdge.
Your sipahrre: _
Mall this form to:
Date: 3
i7 /0 a
Consumer Protection Coordinator

Ten West Street. Third Moor
Boston MA 02111
TY be IS dick h i S 30b -the risht, WCis Orret.h;

Could have, been cbrIQ
0
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tA)

(617) 654-9800
:5%" 6)
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Legal Division Fax,(1317) 357-8453
to
1.1
4)
...I.
Lieenskig Division Fax (617) 4264358
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
Orin Our Website
At nttp://www.messmedboard.org


(817)854.9800
April 3, 2003
Re:
Alain Lester Campbell, M.D.

Docket No: 03-075
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
KM Sls
Visit Our Website At: http://www.massmedboard.org
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
'bell, MD, MSc, Diplomat MOO (1986, recertified 1996)
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
against M.D. r/, D.O.

, Acupuncturist
(For
faints against Chiropractors, Dentate, Nurses, Optometrists, Podiatrists or Psychologists, please
contact
Division of Registration at (617)=-7406, or 239 Causeway St., Boston, MA 02114.)
This
Taint cannot be processed without the fell name of the physician or aarnimclurist Please verify spell.
FoliN
Mat & 14t) of Physician or Acupuncturist (one name per fonn)Pbotocopies are acceptable.
X 01441 CAttelthe fed;
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
Billing for Services Not Rendered

False Advertising
Fraud
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
tohu to this annala
- 'EC
,- / or
- "VC r So 4egra.112
e
If you
;440V1193 for
:feels
Coot the patient what is your relationship to the patient?

0 Ptiend, 0 Attorney, 0 Other
Spouse, U Parent, CI Child, 0 Other Relative
ciao provided treatment in the past? (Do not count the treatment in this complaint)
Han this
Yes, 0 No
Is this ' km the person you (or patient) usually see when you (or patient) ate ill?
Yea, 13 No have you (or patient) been to this physician's cast?
How
I to 30 days, 0 I to 12 morels; 0 I to 2 yens, 0 I. to 4 yeareiir4 tl 0 years or more
ofpayment was made? Check as many as apply.
What
Commucial henuance, %Health Maintenance Organization, 0 Medicaid, 0 Medicare, U Champus
Workers' Compensation, Sett U Otter
Are you or patient) opened to pay a portion of this WI out of pocket?
Yes, t7 No
Has the hysiclim adjusted the bill in any way, for example, was the fee or copayment reduced or waived?
es, 0 No
Is the f or copayment in dispute?
0 Yes, RCM
icing been contacted about this complaint?
Has the
0 Yes, CI No
igd--7/ try( 9/-fry
Dates o
,747,,,,,,,,-,- 0 A eavarc
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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:

560 Harrison Avenue, 0-4
Benton MA 02118
57 2.0a3

(617) 654-9800
MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
MARTIN CRANE, MD
BOARD CHAIR
NANCY ACHIN AUDESSE
nceNcnvE DIRECTOR
May 4, 2005
REDACTED COPY
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,
scoe Trinlmier, Jr., Esquire

mplaint Committee Chair
RT/jab
Enclosure
Visit Our Website At: httm/Avww.massmedboard.org

(617)6549800
Legal Division Fax (617) 357-8453
licensing Division Fat (617) 426-9358
May 17, 2005
Re:

Docket Number 05-035
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
JAB/bmh
Enclosure
Visit Our Webeite At: http://www.massmedboard.org

(617) 654-9800
MITT ROMNEY
GOVERNOR
Enlacement Division Fax; (617) 451-95E8

KERRY HEALEY
LIEUTENANT GOVERNOR
MARTIN CRANE, MO
DoARD GRAM
NANCY ACHIN AUDESSE
EXECUTIVE DIRECTOR
January 26, 2005

9 Boston Street
Suite 9
Lynn, MA 01904-0000
Re:
Dear Dr. Campbell:
The Board of Registration In Medicine has received a complaint regarding your
conduct in the practice of medicine, a copy of which is enclosed. The Board is
obligated by law to investigate such matters relating to the proper practice of medicine.
In compliance with this mandate, the Board's Complaint Committee has directed the
staff of the Board to gather information on all such complaints.
Please provide a written response to the issues raised in the enclosed material.
Your response may be as brief or as lengthy as you choose. Under the law, the person
filing the enclosed complaint may have access to your response.
Your response should be sent to me, at the address above, within thirty days of
your receipt of this letter. After your response Is received, the case may be assigned to
an investigator employed by the Board, who may contact you if further information is
needed. You will in any event be informed in writing as to the disposition of this
complaint. Thank you for your attention to this request.
Very truly yours,
0, OAAA4;
nnifer A.
sumer Protection Coordinator
JAB/som
Visit Our Website At: http://www.massmedboarO.org
LC)
(0

(617) 654-9600
MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
MARTIN CRANE. MD
BOARD CHAIR
NANCY ACHIM AUDESSE
EFECUTIVE DIRECTOR
January 26, 2005
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
JAB/som
visit Our Walsall
http://www.massmedboard.org
0
ID
to

(617) 654-9800
MITT ROMNEY
GOVERNOR

KERRY HEALEY
UEVTENANT GOVERNOR
:0
MARTIN CRANE. MD
BOARD CHAIR
NANCY ACME AUDESSE
EXECUTIVE DIRECTOR
March 14, 2005
Re:

Docket Number: 05-035
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
JAB/bmh
Enclosure
Visit Ovr Websile At: httpwwww.massrnecsoara.org
(41
It
February 23, 2005

Ms Jennifer A. Brown
Boston, MA
.4
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
as a patient for an elective termination of pregnancy.
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.
The "makeshift recovery room", as

, calls it, was actually decorated by a 34
year student of Architecture. It is clean and simple. I admit it does not compare to some
of the Cambridge clinics or surgicenters. Digital pictures are enclosed.
The "broken down chair" is actually a lounger that can be reclined into a bed-like
position, so that patients are more comfortable. I have two of these. The blood pressure
was beeing taken by a wrist digital BP cuff, which she probably never saw before.
The procedure room is clean. The ultra-sound machine is older but still very
functional. Cleaning is done regularly and the usual garbage can is emptied many times a
day. As per law, there are red containers labeled for disposal of needles, syringes, and
spoiled biologic materials, which are picked up by Stericycle (as I am part of the Partners
Health Care Group through hospital affiliations). There is no hair on the floor, but people
walk in and out, and wear boots in the winter. We do clean the floor in between
calls them, are surgical scrub (Iodine), which
customers. The "dirt stains" as
stains the tiles permanently.
I am enclosing a copy of the chart and consent forms she completed. As you can see,
this is one of the most exhaustive pregnancy termination documents used in the field.
Compare them to the state form enclosed. They were developed by an attorney and more
than three gynecologists. When women have questions, I always refer to the consent
forms, because they are very comprehensive, and I answer any additional questions they
. questions about infection, and told her about my
may have. I answered
estimates of risks, which are lower than those on the consent form. I told her the surgery
was considered minor, and she should be fine the next day to go to work. She asked me
about infertility risks. She asked if I could guarantee that she would become pregnant
again, and I told her that no one could guarantee that she would. It is very unlikely that
she would not become pregnant again, as we use new sterile equipment Everybody
receives antibiotic; but there is always a small group of infertile women, and it is a
possibility that she could be part of them. My perception was that she insisted on the
guarantee that she could be pregnant again. This is when I told her she should keep the
pregnancy (I never use the word baby in such a context) if she wanted absolute
warranties, which no one can give.
J partner asked me if I had any history of malpractice suits (he
This is when
4. complaint
did not ask me if my history was above normal, as suggested by
present),
I
answered
yes.
I
have
a
limited
history
of
malpractice
letter- witness
suits. I told him I did not wish to discuss malpractice suits, as they are already reported
with the Board of Medicine, the insurance plans, and the 2 hospitals that I am affiliated
with. I told her there were potential complications associated with pregnancy termination,
and given her great concerns, I did not want her to be my patient. I let her know she
should not have her surgery in a private office but rather in the hospital. Scientific data
show no difference in outcome between abortions performed in the office and hospital
settings. In the past two decades, most abortions were performed in office settings, not in
to " please dress and leave the office, and call
hospitals or surgicenters. I told
Mt Auburn Hospital", where we refer.
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.
Very truly yours,
"p
Alain Campbell, MD, MSc, Diplomate ABOG
8
m0
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
Mailing Address (if different)

--
--
State
City
Zry Cone
ktusTnessfDaytime Phone
Bane Phone
0.0
Acupuncturist
.
Complaint againstMD.
(For complaints against Chiropractors, Dentists, Nurses, Optometrists, Podiatrists or Psychologists, please
contact the Division of Regbtration 14 (617)7274404 or 239 Causeway St., Boston, MA 02114.)
This complaint cannot be processed without the fa name of the physiciam or acupuncturist. Please verify spelling.
Full Name (First & Last) of Physician or Actemecturist (one name per form) Photocopies we acceptable.
Alain L. Comp
M b-
Address
gosion 54. Sulk cl

State
City
MA
Ltirm
Business
901
SI a
Zip Code
svo
0110+
Name and Location of Health Cam Facility (if brown)
44/11*-
A+
6'4 tate
Nature ()Momplaint
I.
0
anti /o r
01161 N
Substandard Medical Can

o
Professional Misconduct
0
Suomi Misconduct
Rude or Discourteous Behavior
Impaired by Alcohol or Drugs
0
impaired by Mental or Emotional Maass 0
0
Failure to Provide Medical Records
A 1 4074 ve
Metitc4 f
Cot
Drug Dealing
Criminal Conviction
Patient Neglect/Abandonment
Unlawful Discrimination
Billing for Services Not Rented
False Advertising
20THER aritlarctti Olt 4 din= ckattial

41,1 um.
"moor- gvesitons
(sea, AW
sUenti4)
Failure to complete and sign this release may prevent investigation of your complaint.
1
rat of Medical Records and Information
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
I FURTHER AUTHORIZE MY MENTAL HEALTH PROVIDER(S) TO DISCUSS EVALUATIONS,

DIAGNOSES OR TREATMENT AND/OR RELEASE ANY AND ALL OF MY MEDICAL RECORDS TO THE
MASSACHUSETTS BOARD OF REGISTRATION IN MEDICINE. THIS AUTHORIZATION REPRESENTS A
WAIVER OF THE PSYCHOTHERAPIST-PATIENT PRIVILEGE, AS DESCRIBED IN G.L. c. 2334 20B.
Signature of Patient
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
IM
OM$
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
Attach copies of related documents to Ws loin

The information in this corniaint is trues comet and comalet, to the beat of my knowledge.
Date. )/15/;00f...
Your signature:
Mail this form to:

560 Hatrison Ave Suite C}4
Boston MA 02118
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.

ALAIN CAMPBELL, M.D. MASSACHUSETTS LICENSE APPLICATIONS Total As of 2015

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ALAIN CAMPBELL, M.D. MASSACHUSETTS LICENSE APPLICATIONS Total As of 2015

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Commonwealth of Massachusetts Board of Registration i

Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-308

Physician Registration Renewal Application

Return renewal application in GREEN envelope.

Renewal Dale: 04/28/2001

Retiring (see instructions)

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

9 Do not wish to renew

Inactive (see instructions)

Please make corrections (type or print)

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

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

8. Drug License Numbers. if any:

5. a) Name of Medical School:

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

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

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

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

VAIN I YOUR L.Aalp4A1VIL:

LICtiilbt. NUMBER: tUarrii

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

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

Letter of Credit '

Alternatively, indicate as follows:

Not involved in direct/indirect patient care in Massachusetts b) 0 Otherwise exempt

Please explain exemption:

Care of patients in Massachusetts (see instruction booklet).

hrs/wk b) inpatient care

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

Commonwealth of Massachusetts Board of Registration in Medicine

Physician Registration Renewal

Return renewal applicatior in t BNiciaMtsfe.

Renewal Date: 04 /28/1999

0 Retiring (see instructions)

0 Inactive (see below')

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

El Do not wish to renew

Please make corrections (type or print)

ALAIN LESTER CAMPBELL, M.D.

5. A) Name of Medical School:

Ivoiire,.: -ke.tiltss as: par c 42cet-dre....Other Address:

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

Full Name of Medical School:

Degree: 0 M.D. 0 D.O.

Hair Peggillatistslis and Gynecology

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

PRINT NAME AND NUMBER: Last Name: CA MPA

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

Commonwealth of Massachusetts Board of Registration in Medicine

Physician Registration Renewal Application

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

ALAIN LESTER CAMPBELL, M.D.

Date of Birth (M/D/Y):

Full Name of Medical School:

5. A) Name of Medical School:

McGill University Faculty of

64 Obstetrics and Gynecolo

Hours Per Week in Mass.

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

If OS, Print Specialty:

PRINT NAME AND NUMBER: Last Name:

Facility Code:___ Facility Code:_

If 999, write Neme(s):