Complaint Form - Maryland Board Of Physical Therapy Examiners

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OFFICE USE 
 
 
 
Case Number 
 
Date Received 
 
MARYLAND BOARD OF PHYSICAL THERAPY EXAMINERS 
 
 
Board Member 
 
Date Reviewed 
 
4201 PATTERSON AVE.  
 
BALTIMORE, MARYLAND 21215‐2299 
Investigator 
 
Date Opened 
 
 
Office: 410‐764‐4752 Fax: 410‐358‐1183 
 
 
COMPLAINT FORM 
 
Please complete this form either on-line or by hand with BLACK ink. You may also type this form. Once completed mail or fax to the
 
above address.
 
The Board is charged with investigating and acting upon complaints against licensed physical therapists and physical therapist assistants. If
your complaint is against a health professional other than a physical therapist or physical therapist assistant, contact this office for the
 
proper addressee. However, if your complaint involves physical therapy care, this information is certainly of interest to the Board and
should be forwarded.
 
As a point of information, Maryland law states "A person who acts in good faith and within the scope of the jurisdiction of the Board
is not civilly liable for giving information to the Board or otherwise participating in its activities."
 
The Board usually will not consider a complaint unless it is signed and dated. All blanks should be filled as completely as possible. Where
 
the information requested is not known, please so state.
 
In order to expedite the processing of your complaint, please write the correct names, addresses and telephone numbers, both home and
business, of all persons named in the complaint.
 
All complaints made to the Board are required by State law to be investigated. Such investigations may take ninety days and in some cases,
more. If the Board decides to bring charges against a physical therapist or physical therapist assistant and to hold a hearing thereon,
 
advance notice will be given to the licensee to enable preparation of a defense. Therefore, in most cases, there is a considerable time lapse
between the filing of the complaint and the hearing, if one is held. In all cases, you will be advised as to the outcome of your complaint.
 
COMPLAINANT
If there is more than one complainant, please use a separate form for each one.
Name
Home Address
Work Address
City, State Zip
City, State Zip
Home Telephone #
Work Telephone #
Date of Birth
E-Mail Address
IF THE COMPLAINT IS MADE BY A PERSON OTHER THAN THE PATIENT, PLEASE FURNISH THE FOLLOWING
ADDITIONAL INFORMATION:
Official Title:
Did you personally investigate the matters set forth in this complaint?
Yes
No
Do you have any written reports or communications with respect to this matter?
Yes
No
Have you made this complaint to any other person or organizations?
Yes
No Whom?
 
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