Complaint Form

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COMPLAINT FORM
PLEASE NOTE: THIS IS NOT AN APPLICATION FOR
MEDICAL MALPRACTICE PRELITIGATION SCREENING.
Do not use this form if you wish prelitigation consideration of a personal
injury claim for money damages. Applications for Prelitigation Screenings are
available at
bom.idaho.gov
under the Prelitigation option.
Please mail your printed or typed complaint to:
Idaho State Board of Medicine, PO Box 83720, Boise, Idaho, 83720-0058.
EXPRESS MAIL: 1755 Westgate Dr., Suite 140, Boise, Idaho, 83704.
I.
Name of Complainant: __________________________________________________
Address: ______________________________________________________________
City/State/Zip: __________________________________________________________
Telephone Home: (__) _____Business: (__) _____Cell: (__) _____FAX: (__) ________
II.
Identifying information about Health Care Provider whom the complaint is being
made:
(Please check appropriate box.)
o
MD/DO
o
PHYSICIAN ASSISTANT
o
Other (SPECIFY)________________________________________________
Name of Health Care Provider: ____________________________________________
Business Address: ______________________________________________________
City/State/Zip: __________________________________________________________
Business Telephone: (____) ___________
Business FAX: (____) __________
Date(s) of Incident or Care_________________________________________________
(Please provide the approximate date(s) you were provided care and/or the date of the incident.)
____________________________________________________________________________
Ill.
Nature of Complaint: Please provide a factual account of what occurred or your
concerns about the care that was provided. Attach additional sheets as needed.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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