Part A: Complainant Information Complainant Name: Address: City: State: Zip Code: Phone Number: Example: 207-555-5555 Email Address: Date of Birth: Example: 01/01/2000 Relationship to Patient: Part B: Patient Information ( Same as complainant information ) Patient Name: Address: City: State: Zip Code: Phone Number: Example: 207-555-5555 Email Address: Date of Birth: Example: 01/01/2000 Part C: License Information Physician or Physician Associate Name: Address: City: State: Zip Code: Phone Number: Example: 207-555-5555 Part D: Complaint Information Note: If you are filing a complaint against several licensees, you must send each one separately. To do this, complete this form, send it and then back up and fill out the information for the next licensee. The rest of the information will still be filled in. Dates of Service Location of Services/Name of Facility Narrative Information Please provide detailed information regarding your complaint to include date(s) of treatment. Critical Info