Get 9735046400 Form

This guide provides clear instructions on how to fill out the 9735046400 Form online. Following these steps will help ensure your complaint is submitted accurately and efficiently.

Follow the steps to complete the 9735046400 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your browser or application.
2. Begin with the consumer information section. Clearly fill in your name, address, and telephone numbers, making sure to include area codes.
3. In the 'Complaint Reported Against' section, input the name and address of the person or business you are filing the complaint against. Include details such as business name, city, state, and ZIP code. If available, insert the license number as well.
4. Indicate your relationship to the consumer or patient. Check the appropriate box reflecting whether you are a self, parent, friend, legal guardian, spouse, sibling, or another relation.
5. Provide the consumer or patient’s information if they are not the same as you. Fill in their name, date of birth, and address.
6. List any additional practitioners or licensees related to the complaint by entering their names, titles, and addresses. Also, include their license numbers and contact information.
7. List all witnesses involved in the complaint. Include their names, addresses, and telephone numbers.
8. Identify the nature of your complaint by checking all that apply and briefly explaining any other concerns not listed.
9. Describe the facts of the complaint chronologically, ensuring clarity and completeness.
10. Outline any prior attempts to resolve the matter before contacting the Board.
11. Attach all relevant documents in readable form, ensuring you do not include any originals.
12. Finally, certify that your information is accurate by signing and dating the form before submission.

Complete and submit your documents online to ensure timely processing of your complaint.