Get Mo 375-1024 2017-2025

This guide provides comprehensive instructions on how to properly fill out the MO 375-1024 form online. It aims to assist users in submitting their complaints effectively and accurately to ensure their concerns are addressed by the Missouri State Board of Registration for the Healing Arts.

Follow the steps to successfully complete the MO 375-1024 form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Complete the 'Complainant Information' section. Enter your last name, first name, prefix, telephone number, address, email address, and, if applicable, the patient's date of birth and social security number (last 4 digits). Be sure to provide a clear relationship to the patient if you are not the patient.
3. Fill in 'Patient Information' if the patient’s address differs from the complainant's address, and ensure to provide their last name, first name, street address, city, state, and zip code.
4. In the 'Subject of Complaint' section, enter the licensee's last name, first name, profession, license number (if known), and their contact details. If there are multiple licensees involved, use a separate form for each.
5. Briefly describe the complaint in a chronological order. Clearly document the facts, including the dates, names, locations, and any relevant details that can support your complaint.
6. Attach copies of any and all related documents to this form to support your claims. These documents will assist the Board in understanding the context and specifics of your complaint.
7. Sign and date both the complaint form and the authorization for the release of medical information form. This authorization allows the Board to collect necessary medical information related to your complaint.
8. Make sure to keep a copy of your completed complaint form for your records, as all submitted materials become part of the licensee's file and cannot be returned.
9. Once you have completed the form, you may save changes, download it, print a hard copy, or send it directly to the appropriate Board office.

Complete the MO 375-1024 form online today to ensure your complaint is heard.