Health Care Provider Complaint Form
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4Health Care Provider Complaint Form
This infomation MUST be completed to investigate your complaint, as we correspond via
U.S. mail. Incomplete forms CANNOT be processed.
Florida Statutes 456.073, Disciplinary proceeding: (1) The department, for the boards under its jurisdiction, shall cause to be
investigated any complaint that is filed before it if the complaint is in writing, signed by the complainant, and legally sufficient.
If an investigation of any subject is undertaken, the Department will furnish to the subject or the subject's attorney a copy of the
complaint or document that resulted in the initiation of the investigation.
Health Care Provider Information:
Name: __________________________________________________________________________________________
First
Last
M.I.
Profession
License Number
Address: ________________________________________________________________________________________
City
State
Zip
Number & Street
Website: ______________________________________
Phone number(s): _______________________________
Complainant Information:
Your Name: ______________________________________________________________________________________
First
M.I.
Last
Address: ________________________________________________________________________________________
City
State
Number & Street
Zip
Home Phone: ________________________ Work Phone: ______________________ Best Time to Call:____________
Patient Information:
Name: __________________________________________________________________________________________
First
M.I.
Last
Address: ________________________________________________________________________________________
City
State
Number & Street
Zip
Phone Number: : ______________________________________________
Date of birth: __________________
Your relationship to the patient:
Parent
Son/Daughter
Spouse
Brother/Sister
Friend
Legal Guardian
Other
Please provide documentation indicating your appointment as the Legal Authority/Guardianship or
Personal Representative
The department does not investigate complaints regarding the amount charged for a
procedure, broken or missed appointments, customer service, bedside manner, rudeness,
professionalism or personality conflicts.
What is the reason for your complaint? Please check all that apply.
Misfilled prescription
Unlicensed
Quality of care
Patient abandonment/neglect
Impaired provider
Abuse
Misdiagnosis
Failure to release patient records
Inappropriate prescribing
Sexual contact
Substance abuse
Other _____________________
Excessive test/treatment
Insurance fraud
Advertising
Date of Incident: ___________________________
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Parent category: Legal