STATEOFOHIO

THESTATElVIEDICALBOARD
VOLUNTARYPERMANENTRETIREMENTFROMTHE
PRACTICEOFMEDICINEAND SURGERY
Do not sign this agreement without reading it. An individual who permanently
surrendersa certificateissued bytheBoardis forever thereafterineligibleto hold a
certificateto practiceorto applyto theBoardfor reinstatementofthecertificateor
issuance ofanynew certificate. You are permitted to be accompanied, represented
and advised by an attorney, at your own expense, before deciding to sign this
voluntaryagreement.
I, Michael XavierMcDonald, M.D., am aware ofmyrights to representation by counsel,
the right ofbeing formally charged and having a formaladjudicative hearing, and do
herebyfreelyexecutethisdocumentandchooseto take the actionsdescribedherein.
I, Michael Xavier McDonald, M.D., do hereby voluntarily, knowingly, and intelligently
retire from the practice ofmedicine and surgery, effective upon the last date ofsignature
below.
I, Michael Xavier McDonald, M.D., do hereby voluntarily, knowingly and intelligently
surrender my renewal card in connection with my certificate to practice medicine and
surgery, LicenseNo. 35.050763,to the StateMedicalBoardofOhio [Board].
I understand that as a result ofthe surrenderherein I am no longerpermitted to practice
medicineandsurgeryin anyfonnormannerin the StateofOhio.
Iagree thatIshall be ineligiblefor, andshall notapplyfor, reinstatementorrestorationof
certificate to practice medicine and surgery, License No. 35.050763, or issuance ofany
othercertificate pursuant to the authorityofthe StateMedical BoardofOhio, on orafter
the date ofsigning this Voluntary Permanent Retirement from the Practice ofMedicine
and Surgery. Any such attempted reapplication shall be considered null and void and
shallnotbeprocessedbytheBoard.
I, Michael XavierMcDonald, M.D., hereby release the State Medical Board ofOhio, its
members, employees, agents and officers,jointlyand severally, from any and all liability
arisingfrom thewithinmatter.
This document shall be considered apublicrecord as that term is used in Section 149.43,
Ohio Revised Code. Further, this information may be reported to appropriate
VoluntaryRetirement
MichaelXavierMcDonald, M.D.
organizations, data banks and governmental bodies. I, Michael XavierMcDonald,M.D.,
acknowledgethatmysocialsecuritynumberwillbeused ifthis informationis soreported
and agreeto providemysocialsecuritynumberto theBoardforsuch purposes.
I stipulate and agree that I am taking the action described herein in lieu of further
investigation of a possible violation of Section 4731.22(B)(l9), Ohio Revised Code,
related to a physical condition which has rendered me incapable ofpracticing medicine
andsurgery.
EFFECTIVE DATE
It is expressly understood that this Voluntary Permanent Retirement is subject to
ratification bythe Board priorto signatureby the Secretaryand SupervisingMemberand
shallbecomeeffective uponthe lastdate ofsignaturebelow.

MICHAELXAVIERMCDONALD,M.D. LANCEA. TALMAGE,M.D.
Secretary
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EnforcementAttorney
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