Statement Of Complaint - Commonwealth Of Pennsylvania Department Of State (Page 3 of 3) in pdf

Statement Of Complaint - Commonwealth Of Pennsylvania Department Of State Page 3

J. RESOLUTION

How would you like this complaint to be resolved?

_____________________________________________________________________

K. COMPLAINANT’S VERIFICATION

I verify that the facts and statements set forth in this complaint are true and correct to the best of my

knowledge, information and belief. I understand that statements in this complaint are made subject to

the criminal penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities.

x________________________________________

x__________________________________________

(FIRST COMPLAINANT’S SIGNATURE)

(SECOND COMPLAINANT’S SIGNATURE, IF ANY)

____________________________________

______________________________________

DATE:

x_______________________________________

(SIGNATURE OF PERSON COMPLETING THIS FORM,

IF OTHER THAN COMPLAINANT)

___________________________________

DATE:

Professional Compliance Office

SUBMIT COMPLETED FORM BY MAIL TO:

Department of State

2601 North Third Street, P.O. Box 2649

Harrisburg, PA 17105-2649

Fax 717 705-2882

OR BY:

L. RECORDS RELEASE (PLEASE COMPLETE IF IT APPLIES TO YOUR COMPLAINT).

TO WHOM IT MAY CONCERN:

THIS WILL AUTHORIZE _____________________________________________________________________________________

(Name of physician, practitioner, hospital or clinic)

to release to the Department of State and its authorized representatives any pertinent medical records and copies of x-rays relating to

_________________________________________________________________________________________________________

(Patient’s name)

for the purpose of investigating a complaint.

_______________________________________________

Signature

Witness

Date:

THANK YOU FOR BRINGING YOUR CONCERNS TO OUR ATTENTION.

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Statement Of Complaint - Commonwealth Of Pennsylvania Department Of State Page 3