Online Complaint Form |
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Individual or Facility Involved in Complaint |
Full Name: |
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License Number: |
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License Type: |
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Tell us about Yourself |
Full Name: |
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Address Line 1: |
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Address Line 2: |
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City: |
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State: |
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Zipcode: |
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Phone: |
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Fax: |
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Email: |
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Mark the box below with an "X" that best answers this: I am filing... |
As the PATIENT: |
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On BEHALF of the PATIENT: |
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As a MANDATORY REPORTER: |
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If not the patient, your relationship to the patient is: |
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Full Name: |
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Date of Birth: |
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Date of Incident: |
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Location of Incident: |
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From: |
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To: |
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Mark the box(es) below with an "X" to indicate those which best describe the nature of your complaint: |
Advertising Violation |
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Charting Irregularities |
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Criminal Conviction |
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Discrimination |
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Excessive Treatment or Testing |
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Failure to Supervise Staff |
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Inappropriate Prescribing |
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Medical Records Release |
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Mental or Physical Impairment |
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Misdiagnosis of Condition |
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Unlicensed Practice |
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Patient Abandonment / Neglect |
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Quality of Care |
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Unprofessional Conduct |
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Sexual Misconduct |
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Substance Abuse |
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Other (provide detail in Complaint Narrative) |
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Yes or No |
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If, 'Yes', what was the result? |
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All complaints are investigated. Please tell us what outcome you are seeking? |
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Yes or No |
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If, 'Yes', with whom (law enforcement, hospital, state agency, etc)? |
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Explain Your Complaint |
Please provide a detailed explanation of your complaint. Include names, addresses, dates, etc. regarding all parties involved. |
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Your complaint will be given serious consideration by the board and further investigative action may be taken, if appropriate. You may be contacted by the board investigator. A referral of a complaint for further investigation does not necessarily mean that a licensing violation has occurred. Investigations are completed as soon as possible, depending upon the nature and circumstances of the complaint. Investigative files are considered confidential for or any purpose other than a hearing before the board; (pursuant to O.C.G.A. 43-1-19(h) (2)). |
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