- I wish to file a complaint against the physician named below.
- I understand that a copy of this complaint will be sent to the physician against whom the complaint is directed and that the Board will request a written response to the complaint from the physician involved.
- A copy of the response will be sent to me unless that response would jeopardize my health or well-being. Orders of the Board relating to disciplinary action against a physician, including orders or other actions of the Board referring or scheduling matters for hearing are a matter of public record.
- I also understand that the processing of this complaint may require investigation by the department of the Attorney General or other investigators and that I may be contacted to answer questions about this complaint. If the complaint pertains to a violation of law outside the scope of the statutes
and rules of the Board, the Board may refer all information to the proper authorities.
Please state the facts of your complaint as clearly as possible below. Include the dates of treatment and names of physicians and other health care providers involved. If you wish to file a complaint against more than one physician, please complete a separate form for each complaint.