Get Ks Form C-100 2016-2025

Filling out the KS Form C-100 is a crucial step for individuals wanting to submit a complaint to the State Board of Pharmacy. This guide will take you through the process of completing this form online, ensuring you provide all necessary information clearly and accurately.

Follow the steps to fill out the KS Form C-100 online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your browser.
2. Begin by entering your personal information in the 'Name of Person Registering Complaint' section. Ensure to provide your permanent mailing address, city, state, and zip code.
3. Input your contact details, including your home phone number, cell phone number, and email address. This information is essential for the Board to reach you if further verification is needed.
4. Fill in the section for the patient’s information. Provide their name, date of birth, and your relationship to the patient.
5. Specify the pharmacy's details by entering the name and address of the pharmacy involved in the complaint.
6. In the 'Details of Complaint' section, describe the events in the order they happened. Be as detailed as possible, using additional sheets if necessary.
7. Respond to the 'Action Taken' section by indicating whether you discussed the matter with the pharmacist and provide details of that contact.
8. If applicable, fill out the section regarding the prescribing doctor, including their address and telephone number.
9. Answer the questions related to patient harm, counseling provided, and whether any medications were taken.
10. Indicate your willingness to testify against the individual if your complaint is against a licensed person.
11. Reflect on the outcome you wish to achieve as a result of this complaint, providing a clear statement of your expectations.
12. Finally, verify the information entered is true and complete. Sign and date the form to validate your submission.
13. After completing all fields, you can save changes, download, print, or share the form as necessary.

Complete your document submissions online for efficiency and effectiveness.