STATE AND CONSUMER SERVICES AGENCY- Department of Consumer Affairs EDMUND G. BROWN JR. Governor MEDICAL BOARD OF CALIFORNIA Central Complaint Unit CONSUMER COMPLAINT FORM Instructions for Filing Your Complaint Fill in the full name and address telephone number license number if known of the person your complaint is against. Except for the name of the physician all information requested is voluntary but failure to provide the requested information may delay or prevent the investigation of your complaint. Provide as much information as possible in connection with the complaint. The information on the complaint form will be used in part to determine whether a violation of State Law has occurred. If a violation is substantiated the information may be transmitted to other government agencies including the Attorney General s Office. I wish to complain about the individual named below. I understand that the Medical Board does not assist citizens seeking return of their money or other personal....
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How to fill out the CA Medical Board Form 071-61 online
The CA Medical Board Form 071-61 is essential for individuals wishing to file a consumer complaint against a healthcare provider. This guide will help you navigate the online process of completing this form, ensuring that you submit your complaint accurately and efficiently.
Follow the steps to successfully complete the form online.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- Carefully print or type all required information legibly, ensuring clarity in each section.
- Provide the full name and address of the licensee related to your complaint. Note that the Medical Board only reviews complaints against listed individuals.
- Attach any relevant supporting documents related to your complaint. This may include patient records, photographs, recordings, and correspondence.
- Sign and date the complaint form in the designated area to confirm the information is accurate.
- Complete the ‘Authorization for Release of Information For The Subject Of The Complaint’ section, specifying the healthcare provider you are complaining about.
- Fill out one of the medical release forms provided, either the 'Physician/Provider/Facility Authorization for Release of Information' or the 'Kaiser Authorization for Release of Information', including details about treatment facilities and providers.
- If applicable, ensure that any signatory for the release form is a legal representative, with documentation provided to verify their authority.
- Once completed, review the form for accuracy, then save changes, download the form, print it for your records, or share it as needed.
Complete your CA Medical Board Form 071-61 online today to file your consumer complaint.
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