Complaint Form

Date: 
09/30/2019
Document File: 
Document Text Version

IOWA BOARD OF MEDICINE

400 SW EIGHTH STREET SUITE C

DES MOINES, IOWA 50309

PHONE: 515-281-5171

FAX: 515-281-8641

Web: www.medicalboard.iowa.gov

 

 

COMPLAINT FORM

One  of  the  most  important  ways  the  Iowa  Board  of  Medicine  protects consumers is by investigating their complaints against physicians.   This form helps the Board collect basic information to review your complaint. For an explanation of  the complaint investigation process, please  call  the Board’s Enforcement Division, 515-281-5847, or visit the Board’s  website, www.medicalboard.iowa.gov   Please provide the following information so that the Board can acknowledge receipt  of your  complaint  and contact you should additional  information be needed:

 

 

NAME:                                                                                                                     

(LAST)                                     (FIRST)                        (MIDDLE INITIAL)

 

ADDRESS:                                                                                                               

 

 

DAYTIME PHONE:                                                                                                          

 

E-MAIL ADDRESS:                                                                                                            

 

DATE OF BIRTH:                                                                                                             

 

YOUR GENDER:

(CHECK ONE)

Male                    Female                  Unsure                 Anonymous

N/A

PATIENT INFORMATION

NOTE:    If    you    are    not    the    patient,     please    provide    the     following information:

 

PATIENTS NAME:                                                                                                        

(LAST)                                          (FIRST)                            (MI)

 

ADDRESS:                                                                                                                            

 

DAYTIME PHONE:                                                                                                          

 

E-MAIL ADDRESS:                                                                                                            

 

PATIENTS DATE OF BIRTH:                                                                                       

PATIENT’S GENDER:

(CHECK ONE)

Male                    Female                  Unsure                 Anonymous

N/A

 

RELATIONSHIP OF COMPLAINANT TO PATIENT:

(CHECK ONE)

Patient

Spouse

Relative (SPECIFY:                                                                                                  )

No Relation

Name of clinic/hospital where care occurred _________________________

PHYSICIAN INFORMATION Please provide the following information about the physician(s) who is the subject of your complaint:

PHYSICIAN’S NAME:                                                                                                     

(LAST)                                     (FIRST)

OFFICE ADDRESS:                                                                                                        

OFFICE PHONE:                                                                                                             

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

PHYSICIAN’S NAME:                                                                                                     

(LAST)                                     (FIRST)

OFFICE ADDRESS:                                                                                                        

 

OFFICE PHONE:                                                                                                             

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

PHYSICIAN’S NAME:                                                                                                     

(LAST)                                     (FIRST)

OFFICE ADDRESS:                                                                                                        

 

OFFICE PHONE:                                                                                                             

COMPLAINT INFORMATION Please describe complaint, including dates and issues. (Use additional pages if necessary and add copies of records if available.)

Today’s Date:                                                                                   

 

QUESTIONS ABOUT COMPLAINT

 

 

 

1.  Did you discuss the complaint with the physician? YesNo

Explain:

 

 

 

 

 

 

 

 

 

 

2.  Did you obtain an opinion from another physician about your complaint? Yes No

Explain:

 

 

 

 

 

 

 

 

 

3.  Have you contacted another regulatory agency or an attorney about your complaint? Yes No

Explain:

 

 

 

 

 

 

 

 

 

4.  Do you have/did you have a professional relationship (business, employment, etc.) with the physician?  Yes No

Explain:

 

 

 

 

 

 

 

 

5.  Do you have/did you have a personal relationship with the physician?

YesNo

Explain:

 

 

 

 

YOUR EXPECTATIONS

 

What would you like the Iowa Board of Medicine to do about your complaint?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAIL OR FAX FORM

IOWA BOARD OF MEDICINE

400 SW EIGHTH  STREET SUITE C

DES MOINES, IOWA 50309

FAX: 515-281-8641

 

 

 

Complaint Attachment

 

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

(Iowa Board of Medicine)

 

Patient Name:                                                      Date of Birth:                                               

Phone Number:                                           

Address:                                                                                                                                            . City: _________________________________  State:__________  Zip Code:______________

I hereby authorize the release of my personally identifiable protected health information to the Iowa Board of Medicine (IBM) for use in a confidential investigation being conducted by the IBM. This authorization includes records of a public, private or confidential nature, including the following:

 

[ x ]  Consultation                  [ x ]  History & Physical                    [ x ]  Operative Report

[ x ]  Assessment/Evaluation  [ x ]  Treatment Summary                 [ x ]  Social History

[ x ]  Discharge Summary      [ x ]  Lab, X-ray, EKG                       [ x ] Pathology Report

 

I understand that I may revoke this release in writing at any time, except to the extent that the IBM has already taken action in reliance upon this release.  I understand that this release shall remain valid for the duration of the IBM investigation unless revoked by me.  I understand that I have a right to inspect the information to be disclosed upon proper notification to and under appropriate conditions as established by the IBM. I understand that my authorization is voluntary and that my health care will not be affected if I do not sign this form. I acknowledge that I have been provided a copy of this authorization.

 

SPECIFIC RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW I specifically authorize the release of protected health information relating to:

(Please check appropriate boxes)

 

[  X ] Mental Health     [ X  ] Drug and Alcohol Abuse Records  [ X  ] HIV/AIDS Test Results

 

I have read and fully understand the contents of this "Authorization to Release Information."

 

 

 

 

Signature of Patient or Patient’s Authorized Representative ___________________________________________     Date ___________________

 

PROHIBITION ON REDISCLOSURE

This form does not authorize re-disclosure of medical information beyond the limits of this consent.  Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42

C.F.R. Part 2) and state requirements (Iowa Code Ch. 228) prohibit further disclosure without the specific written consent of the patient except as otherwise permitted by such law and/or regulations.   A general authorization for the release of medical or other information is not sufficient for these purposes.  Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.

 

A photocopy/reproduction of this authorization shall have the same force

Document Category: 

Printed from the Iowa Board of Medicine website on October 31, 2020 at 8:44pm.