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Office of Professional Medical Conduct, New York State Department of Health

Complaint Form

Please print and complete and return to the Office of Professional Medical Conduct, 433 River St., Suite 303, Troy, NY, 12180-2299

(This form will not be sent electronically.)

-- See instructions --

All reports of misconduct are kept confidential and are protected from disclosure according to New York State Public Health Law, Sections 230(10)(a)(v) and 230(11)(a). Any person who reports or provides information to the Board for Professional Medical Conduct in good faith, and without malice, shall not be subject to an action for civil damages or other relief as the result of making the report according to Section 230(11)(b).

INFORMATION ABOUT YOU

Name_____________________________________________________________________________
Address___________________________________________________________________________
City_______________________________________State__________________Zip_______________
Telephone Day (____)_________________ Evening (____)____________________

(If you do not have a daytime telephone number, please provide a number where a message can be left for you during the day).

PHYSICIAN OR PHYSICIAN ASSISTANT

Name____________________________________________________________________________
Address__________________________________________________________________________
City_______________________________________State__________________Zip______________
Telephone (____)________________________

COMPLAINT

Describe your complaint as completely as you can. Please sign and date the form.

Patient's Name___________________________________________________________________
Date of Birth_____/_____/_____
Social Security Number___ ___ ___ - ___ ___ - ___ ___ ___ ___

When did this happen?____________________________________________________________

Where did this happen?___________________________________________________________

Have you filed a complaint with anyone else? Yes_________ No _________

If yes, with whom?________________________________________________________________

Names of Witnesses_______________________________________________________________

_______________________________________________________________________________

Description______________________________________________________________________

_______________________________________________________________________________

Signature_____________________________________________Date_______________________

DOH-3867www (7/97)