Get Department Of Public Health Petition Form 1 Please Fill Out And Return To: State Of Connecticut

Filling out the Department Of Public Health Petition Form 1 is a crucial step for individuals wishing to lodge a formal complaint regarding healthcare providers in Connecticut. This guide provides clear instructions to help users accurately complete the form online.

Follow the steps to successfully complete your petition form.

1. Click ‘Get Form’ button to access the petition form and open it in your preferred editing tool.
2. Complete the Petitioner/Complainant section by entering your name, date of birth, address, and telephone numbers. Additionally, specify your relationship to the patient involved.
3. Fill out the Patient information section only if the patient is different from the petitioner. Include the patient's name, address, date of birth, and telephone numbers.
4. In the Respondent/Healthcare Provider section, provide the name and practice address of the healthcare provider being complained about, along with their profession/specialty and telephone number.
5. Indicate the nature of your complaint by checking the appropriate box(es). Ensure to specify the grounds of your complaint clearly.
6. In the description section, detail your concerns, providing specific information about who, what, when, where, and why the complaint is being made. Use additional sheets if necessary.
7. List any prior and/or subsequent treating practitioners, including their names, telephone numbers, and addresses.
8. Document any witnesses' information by including their full names, telephone numbers, and addresses.
9. Attach any relevant supporting documents that may strengthen your complaint, such as photographs, records, or correspondence.
10. Fill out and sign the attached Consent for Release of Medical Records section, ensuring that it is notarized as required.
11. Review all fields for completeness and accuracy before saving your changes, downloading, printing, or sharing the form as needed.

Ensure your voice is heard by filling out and submitting your petition online today.