Board of Medicine

Complaint Form

Person Registering Complaint

Please provide the following information so that we may acknowledge receipt of your complaint and may contact you should we need further information. You can also download the complaint form in .PDF format from HERE.

The submission of this form does not provide us with your e-mail 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 
Your Date of Birth:*
Your Gender:*
If you wish you may provide an e-mail address.
Your e-mail 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:
  
Patient's Gender:
Relationship of
Complainant to Patient:
If "Relative" Specify
Relationship:

Complaint Filed Against

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

Physician's Name:*
First* Middle Last*
Address:*
City:*
State:*
Zip Code:*

NOTE: If you are filing complaints 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.

Questions About Your Complaint

1. Did you discuss this complaint with the physician?

Explain:

2. Did you obtain an opinion from another physician about your complaint?

Explain:

3. Have you contacted an attorney or another regulatory agency about your complaint?

Explain:

4. Do you have/did you have a professional relationship (business, employment, etc.) with the health care provider?

Explain:

5. Do you have/did you have a personal relationship with the health care provider?

Explain:

Your Expectations

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

*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 Luann Brickei at 515-242-3252, or by e-mail.

 

return to home page