Dental Complaint Form Page 3
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3If this complaint is against a person or entity licensed by the Dental Board, are you willing to testify in person
regarding this matter at a formal hearing?
Yes, I am willing.
No, I am not willing.
What action by the Board would address your complaint?
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NATURE OF COMPLAINT
Misdiagnosis of condition
Inappropriate prescribing
Impairment
Patient abandonment/neglect
Fraud
Unlicensed practice
Inferior Treatment - quality of care provided
Business practice Issues
Other (specify)
Unable to obtain dental records or x-rays
DATE(S) OF INCIDENT(S): _______________
DETAILS OF COMPLAINT: Clearly describe the incident(s) leading up to your complaint. If applicable, attach copies
of documents such as medical and/or dental records, photographs, bills, insurance statements, cancelled checks,
correspondence, prescriptions, witness statements, etc. that support your statements. DO NOT SEND ORIGINALS.
Attach extra paper as needed to complete this section.
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AUTHORIZATION FOR RELEASE OF RECORDS AND REFERRAL OF COMPLAINT
My signature on this form, or photocopy thereof, authorizes the Department of Public Health Bureau of Health Professions
Licensure to: (1) receive copies of all my health records relating to my complaint; (2) to share the complaint and all
records collected by the Bureau of Health Professions Licensure during the investigation of my complaint with the
licensee for the licensee’s use in responding to the allegations in this complaint; and (3) to refer my complaint to other
regulatory and/or law enforcement authorities for appropriate action.
I understand that all complaints are investigated to determine their factual basis.
The act of filing a complaint and its receipt and/or investigation by DPH does not mean that disciplinary action will be
taken against the licensee.
I hereby declare that I am at least 18 years old and affirm under penalties of perjury that the information provided in
connection with the foregoing complaint is true and correct to the best of my knowledge, information and belief.
_____________________________________________
____________________________
Signature of
Date
Patient or
Legal Representative, or
Mail this form to:
(attach documentation)
Department of Public Health
Bureau of Health Professions Licensure
Other Complainant
239 Causeway Street, 5
th
Floor
Boston, MA 02114
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