Complaint being filed by:

Full Name

Home Address

Home Phone

Work Phone

Complaint being filed against:

Full Name

Name of Facility

Facility Address

Facility Phone

Nature of Complaint:

1. - Were you a patient of this professional?

If Yes, list dates of treatment. If No, state your reason for involvement in this complaint and proceed to Question 3.

2. - For what condition(s) were you being treated?

3. - Have you discussed your complaint with the professional?

If Yes, what were the results? If No, why not?

4. - If you were a patient include billing records or other documentation in your possesion that will assist the Board in its investigation of your complaint.

5. - Have you filed this complaint with any other person or organization?

If Yes, with whom?

Name:

Address:

Phone:

Witness Information:

List individuals who are witnesses to the incident(s).

Name:

Address:

Phone

Name:

Address:

Phone

List individuals who have knowledge of the incident(s).

Name:

Address:

Phone

Name:

Address:

Phone

Consent for Release of Information:

Do you consent to the release of all treatment records and documentation relating to your care to the Board to assist with the investigation of your complaint?

I hereby declare and affirm that the information given above regarding my complaint is, to the best of my knowledge, accurate and true.