Online Complaint Form

Individual or Facility Involved in Complaint

Full Name:

License Number:

License Type:

Tell us about Yourself

Full Name:

Address Line 1:

Address Line 2:

City:

State:

Zipcode:

Phone:

Fax:

Email:

Mark the box below with an "X" that best answers this: I am filing...

As the PATIENT:

On BEHALF of the PATIENT:

As a MANDATORY REPORTER:

If not the patient, your relationship to the patient is:

Patient Information

Full Name:

Date of Birth:

Date of Incident:

Location of Incident:

Date(s) of Care:

From:

To:

Nature of Complaint

Mark the box(es) below with an "X" to indicate those which best describe the nature of your complaint:

Advertising Violation

Charting Irregularities

Criminal Conviction

Discrimination

Excessive Treatment or Testing

Failure to Supervise Staff

Inappropriate Prescribing

Medical Records Release

Mental or Physical Impairment

Misdiagnosis of Condition

Unlicensed Practice

Patient Abandonment / Neglect

Quality of Care

Unprofessional Conduct

Sexual Misconduct

Substance Abuse

Other
(provide detail in Complaint Narrative)

Have you addressed your concerns with the person listed in this complaint?

Yes or No

If, 'Yes', what was the result?

All complaints are investigated. Please tell us what outcome you are seeking?

Have you filed a complaint with anyone else?

Yes or No

If, 'Yes', with whom
(law enforcement, hospital, state agency, etc)?

Explain Your Complaint

Please provide a detailed explanation of your complaint.
Include names, addresses, dates, etc. regarding all parties involved.

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)).