BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY - Department of Consumer Affairs

EDMUND G. BROWN JR., Governor

MEDICAL BOARD OF CALIFORNIA
Central Complaint Unit

Date

Subject Full Name
Subject Address
Subject City, ST Zip

Patient:
Patient Date of Birth:
Patient Date of Death:
Control Number:
Date(s) of Service:

Patient Full Name
Patient Date of Birth
Patient Date of Death
Control No
Date(s) of Service

Dear Dr. Subject Last Name:
The Medical Board of California (Board), based on data requested and received from the
California Department of Public Health, is examining deaths associated with the use of
prescription opioids and is reviewing whether the care and treatment provided by physicians to
those individuals met the standard of care for the time period in question. As part of this review,
the Board has received information regarding the death of [Patient Full Name]. Please be aware
that the Board understands that just because a patient death occurred, it does not automatically
mean the physician deviated from the standard of care or otherwise violated the Medical Practice
Act. A review such as these are routine, particularly in the midst of the current national opioid
crisis with an alarming rate of overdose deaths that require close attention by the Board.
In order to track this matter through the review process, the Board has opened this matter with
the control number identified above. Pursuant to the provisions of Section 800(c) of the
Business and Professions Code, we are providing a comprehensive summary of the matter as
follows:
Insert allegations
Pursuant to Section 2220.08(a)(2)(B) of the Business and Professions Code, the Board is asking
for your response to the summary provided above. Please provide a written summary of the care
and treatment rendered to this patient and a copy of your curriculum vitae. You may also
provide any additional expert testimony or literature that you feel would be pertinent to the
Board in evaluating this matter.
Additionally, the Board has been unable to locate or contact the deceased patient’s beneficiary or
personal representative. Please see the attached declaration indicating the Board has met the
statutory requirements to require the release of the records. As such, in accordance with
Business and Professions Code section 2225(a)(c)(1), the Board is requesting that you provide
CERTIFIED copies of the deceased patient’s medical records, including diagnostic images if
2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2528 FAX: (916) 263-2435 www.mbc.ca.gov

 applicable, to the Board. Please complete the enclosed Certification of Records/Declaration of
Custodian of Records to certify that the records are a “true copy” and a complete set and return it
with the records to the address shown below. It would be appreciated if you would also include
a copy of this letter with your response. Pursuant to Business and Professions Code sections
2225(e) and 2225.5 (copy enclosed), failure to produce the records by the date requested may
result in citation and fine or assessment of civil penalties of $1,000 per day.
The records, summary and a copy of your curriculum vitae are to be provided by Response Date.
Please send this material to the attention of:
Analyst Name
Medical Board of California
2005 Evergreen St., Suite 1200
Sacramento, CA 95815-3831
If you are not the custodian of the patient’s records, please provide the Board with the name of
the facility where the patient’s care was provided.
The Board is a regulatory licensing and enforcement agency requesting this information for a
confidential review. If you would like more information about the Board’s complaint and
investigation process, please review the enclosed Newsletter articles titled, “Do Not Panic!
What Should You Expect if a Complaint is Filed Against You?” and “What Should You Expect
if There is an Investigation after a Complaint has been Filed?” Please be aware that this initial
review is not public and is not posted on your physician profile. If you have any questions,
please feel free to contact me.
Thank you for your cooperation in this matter.
Sincerely,

Analyst Name
Analyst Job Title
Analyst Phone No
Enclosures:

Business and Professions Code Section 2225.5
Declaration of Custodian of Records/Certification of Records

NOTICE: A licensee that fails to provide the certified medical records within 15 days, or a
health care facility within 30 days, of receipt of a request for certified medical records may
constitute a violation of Sections 2225(e) and 2225.5 of the Medical Practice Act (copy
enclosed) and may result in a civil penalty of $1,000 per day for each day that the
documents have not been produced.
Effective January 1, 2014: For health care facilities that have electronic health records,
failure to provide the authorizing patient’s certified medical records to the board within 15
days of receiving the request, authorization, and notice shall subject the health care facility
to a civil penalty, payable to the board, of up to one thousand dollars ($1,000) per day for
each day that the documents have not been produced after the 15th day, up to ten thousand

 dollars ($10,000), unless the health care facility is unable to provide the documents within
this time period for good cause.
“Certified medical records” is defined as “a copy of the patient’s medical records
authenticated by the licensee or health care facility, as appropriate, on a form prescribed
by the board.”