Form 071-61 - Consumer Comp[liant Form - Medical Board Of California
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4BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY – Department of Consumer Affairs
EDMUND G. BROWN JR., Governor
MEDICAL BOARD OF CALIFORNIA
Central Complaint Unit
CONSUMER COMPLAINT FORM
Instructions for Filing Your Complaint
Fill in the full name, address, telephone number, and license number (if known) of the person your complaint
is against. Also write this information in the corresponding section of the Authorization for Release of
Medical Information Form on the reverse side of the Complaint Details Form.
If the patient has seen another doctor for the same problem, include the name, address and date(s) of
treatment in the complaint details.
Write your complaint and include as many specific details as possible (who, what, when, where, why).
Include the date(s) of treatment and specific examples of the problems with the care and treatment, using
extra sheets of paper if needed.
Pursuant to Business and Professions Code Section 2230.5 the Medical Board must file an Accusation (formal
charges) against a doctor’s license within three (3) years of the date the Board is first notified of the act or
omission alleged as the ground for disciplinary action or seven (7) years from the date of the incident,
whichever occurs first. Accordingly, please immediately send us copies of any documents that may assist the
Board in investigating the allegations. Documents may include patient records, photographs, audiotapes,
correspondence, billing statements, proof of payments, etc.
Sign and date the complaint form and the Authorization for Release of Medical Information Form.
Authorization for Release of Medical Information
The Authorization for Release of Medical Information Form found on the reverse side of the Complaint Details Form
is a legal authorization for the Medical Board’s staff to obtain information about the patient’s care from the doctors
and/or medical facilities involved in the medical care. ANY EXTRA COMMENTS, NOTATIONS, ETC., MAKE
THE FORM VOID AND WE WILL HAVE TO ASK YOU TO COMPLETE ANOTHER RELEASE FORM.
If you wish to provide us with additional information, please do so using a separate sheet of paper. If there is more
than one physician involved in the patient’s care, you may copy the blank form and complete one for each physician
and/or facility. When a medical record release form is completed and signed, it allows the Medical Board to order
records from ONLY the doctors or facilities you have listed on the medical record release form(s).
Print or type the patient’s name, date of birth, date of death, and medical record number (if known) in the first
section. FILL IN THE FULL NAME AND ADDRESS OF THE PERSON YOU ARE COMPLAINING
ABOUT IN THE NEXT SECTION. Fill in the names and addresses of all other health care providers where the
patient was seen for the medical problems in this specific complaint (doctors and/or clinics or hospitals, etc.) using
the other medical release forms. If we need to contact you to clarify your information, it will delay the review
process.
NOTE: The release form(s) must be signed and dated by either the patient or the individual legally authorized to
make medical decisions for the patient. If the patient is unable to sign the release, the form may be signed by: 1)
the next of kin, if the patient is deceased (provide a copy of the Death Certificate); 2) the parent of a minor child; or
3) the person named by the patient in a signed Power of Attorney granting the person authority to make medical
decisions for the patient (provide a copy of this document).
07I-61 (Revised 9/2017)
2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2528 FAX: (916) 263-2435
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