IBM Complaint Form

Date: 
04/02/2021
Document File: 
Document Text Version

IBM 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) 281-5171, or visit the Board’s website, https://medicalboard.iowa.gov/physicians/enforcement. Please provide the
following information so that the Board can acknowledge receipt of your complaint and contact you should additional information be needed:

Complainant Information:

Complainant’s Name:

Complainant’s Address:

Your Phone Number:

Email:


Patient Information:

*If you (the complainant) are not the patient please provide the patient’s information below.

Patient’s Name:

Patient’s Address:

Patient’s Phone Number:

Patient’s DOB:

Patient’s Gender:

Relationship of Complainant to Patient:

If a relative, please describe:

Physician(s) Information:

Physician 1 (Name):

Physician 1 (Office Address):

Physician 1 (Office Phone Number):

Name of Hospital or Clinic Where Care Occurred:

Approximate Date or Date Range of Care:

Physician 2 (Name):

Physician 2 (Office Address):

Physician 2 (Office Phone Number):

Name of Hospital or Clinic Where Care Occurred:

Approximate Date or Date Range of Care:

Physician 3 (Name):

Physician 3 (Office Address):

Physician 3 (Office Phone Number):

Name of Hospital or Clinic Where Care Occurred:

Approximate Date or Date Range of Care:

Complaint Information:

Complaint Information Cont’d:

Questions:

Did you discuss the complaint with the physician?

YES or NO

If yes, please explain:

 

 

 

 

Did you obtain an opinion from another physician about your complaint:

YES or NO

If yes, please explain:

 

 

 

 

Have you contacted another regulatory agency or an attorney about your complaint:

YES or NO

If yes, please explain:

 

 

 

 

Do you have/did you have a professional relationship (business, employment, etc.) with the physician?

YES or NO

If yes, please explain:

 

 

 

 

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

YES or NO

If yes, please explain:

 

 

 

 

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

 

 

 

 

 

Mail, Fax, or Email complaint to:
Iowa Board of Medicine
ATTN: Complaints
400 SW 8th St., Ste. C
Des Moines, IA 50309
FAX: (515) 281-8641
EMAIL: IBMComplaints@iowa.gov

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 and effect as the original.

Document Category: 

Printed from the Iowa Board of Medicine website on June 21, 2021 at 8:56pm.