Get CA Medical Board Form 071-61 2020-2024

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 remedies. I am however submitting this information so that it may be determined whether disciplinary action against this practitioner s license should be considered. Check one Physician M. Include the date s of treatment and specific examples of the problems with the care and treatment and use extra sheets of paper if needed. Send us copies of any documents in support of your complaint which may include patient records photographs audiotapes correspondence billing statements proof of payments etc. Sign and date the complaint form at the bottom of the page and on the Authorization Release Form. Authorization for Release of Medical Information The Authorization for Release of Medical Information found on the reverse side of the Complaint Details form is a legal authorization for the Medical Board s staff to obtain information about the patient s care from the doctors and/or medical facilities involved in the medical care. ANY EXTRA COMMENTS NOTATIONS ETC. MAKE THE FORM VOID AND WE WILL HAVE TO ASK YOU TO COMPLETE ANOTHER RELEASE FORM. When this form is completed and signed it allows the Medical Board to order records from ONLY the doctors or facilities you have listed on the medical record release form. Print or type the patient s name date of birth date of death and medical record number if applicable. If we need to contact you to clarify your information it will delay the review process. FILL IN THE FULL NAME AND ADDRESS OF THE PERSON YOU ARE COMPLAINING ABOUT IN THE FIRST SECTION. Fill in the names and addresses of all other health care providers where the patient was seen for the medical problems in this specific complaint doctors and/or clinics or hospitals etc. using the other sections on the medical release. Also write this information in the first section of the Authorization for Release of Medical Records on the reverse side of the Complaint Detail Form. If the patient has seen another doctor for the same problem include the name address and date s of treatment on the release section of the complaint form. Write your complaint and include as many specific details as possible who what when where why. Include the date s of treatment and specific examples of the problems with the care and treatment and use extra sheets of paper if needed. Send us copies of any documents in support of your complaint which may include patient records photographs audiotapes correspondence billing statements proof of payments etc. Sign and date the complaint form at the bottom of the page and on the Authorization Release Form. Authorization for Release of Medical Information The Authorization for Release of Medical Information found on the reverse side of the Complaint Details form is a legal authorization for the Medical Board s staff to obtain information about the patient s care from the doctors and/or medical facilities involved in the medical care. D. Podiatrist DPM Assistant PA Registered Dispensing Optician RDO Midwife COMPLAINT REGISTERED AGAINST Office/Facility Name Street Address License No. If known Address Zip Code Has the patient been examined/treated by another professional for this same condition No Yes If yes provide name and address on the Authorization for Release of Medical Information Reason for Treatment Date s of Treatment DETAILS OF COMPLAINT Attach additional sheets if necessary AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Date of Birth Medical Record Number If applicable Date of Death If applicable Control Number Social Security No. Optional I the undersigned hereby authorize Physician/Facility Address City/State/Zip Code Treatment Date s to disclose medical records in the course of m y diagnosis and treatment to the Medical Board of California Enforcement Program a healthcare oversight agency. I. Mailing Address City Phone Number Daytime Number Patient Name Patient Date of Birth State Zip Evening Number Cell phone/E-mail address Your Relationship to Patient NATURE OF COMPLAINT Please check the box which best describes the nature of your complaint and provide details on the next page Substandard Care e.g. Misdiagnosis Negligent Treatment Delay in Treatment etc. Prescribing Issues e.g. excessive/under prescribing Internet Unlicensed Provider orAiding/Abetting unlicensed practice Sexual Misconduct Physician/Provider Impairment e.g. Drug Alcohol Mental Physical Unprofessional Conduct e.g. Breach of Confidence Record Alteration Fraud Misleading Advertising Arrest or conviction Office Practice e.g. Failure to Provide Medical Records to Patient Failure to Sign Death Certificate Patient Abandonment Other Notice The information included on the complaint form is requested per Section 2220 of the Business and Professions Code. 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 remedies.