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Complaint Form

Person Registering Complaint

Please provide the following information so that we may acknowledge receipt of your complaint and that we may contact you should we need further information.

The submission of this form does not provide us with your Email address unless you provide it in the form below.

* Required Fields
Your Name:*
First* Middle Last*
 
Address:*
City:*
State:*
Zip Code:*
Daytime Phone:*
 Include Area Code 
Patient's Date of Birth:
  
If you wish you may provide an Email address.
  Your Email address is 

Patient Information

Is the patient information the same as the complainant information? *

If patient information is NOT the same as the complainant information please provide the information below.

Patient's Name:
First Middle Last
 
Address:
City:
State:
Zip Code:
Daytime Phone:
 Include Area Code 
Patient's Date of Birth:
   If not listed above

Complaint Filed Against

Please supply specific information regarding the provider physician you are filing a complaint against, to include the provider's full name and practice location.

Physician's Name:**
First** Middle Last**
Address:**
City:**
State:**
Zip Code:**
Daytime Phone:**
 Include Area Code 

Note:  If you are filing a complaint against several physicians, 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 physician.  The rest of the information will still be filled in.

Narrative Information *

Provide detailed information regarding your complaint and include date(s) of treatment.

*Check this box if you are ready to submit this complaint and click the submit button below.

If you should encounter any problems with this process, or wish to speak to someone, please contact Ed Knapp, Chief Investigator at 515-281-5847, or by email.