Fillable Complaint Form (Page 2 of 2) in pdf

____________________________________________________________________________

IV.

Is this Health Care Provider your primary health care provider? Yes

Were you referred to this Health Care Provider?

Yes

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize and direct any hospital, physician or other person who has any

information regarding my medical care and treatment to release any and all medical records,

reports and/or information to the Idaho State Board of Medicine or to such other representative

of the Idaho State Board of Medicine as may be designated, for examination and for copying

thereof, upon request for such records, reports or information for the specific purpose of

addressing concerns relevant to my medical care and treatment.

I further authorize any hospital, physician or other person who has such information to

consult with or discuss such information with any of the above entities or persons.

I further consent that a photocopy of this Authorization may be used in lieu of the original

hereof and shall be considered valid for one (1) year from the date of my signature below. This

authorization, however, is revocable upon receipt of my written request by the Idaho State

Board of Medicine.

DATED this ____ day of _______________, 20___.

Signed: ____________________________________________, Complainant

Printed Name: _______________________________________, Complainant

A SUBMITTED COMPLAINT FORM WITHOUT A SIGNATURE IS NOT ACCEPTED.

VI. NOTIFICATION

You will be notified of the Idaho State Board of Medicine’s (Board) receipt of your complaint.

You may be requested to provide additional information and/or documentation supporting your

complaint.

When the Board conducts an investigation, it is handled in a confidential and

discrete manner as required by state law. A request for confidentiality cannot be respected in

accordance with fairness and procedural process.

The provider named in your complaint (Respondent) will also be notified and will be

provided a copy of your complaint. The Respondent will be requested to answer and provide

copies of relevant documents, including medical records. Both you and the Respondent will be

updated every 45-60 days until the matter is resolved.

Rev. 08/2010

Complaint Form Page 2