Form 071-61 - Consumer Comp[liant Form - Medical Board Of California Page 2

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MEDICAL BOARD OF CALIFORNIA
CONSUMER COMPLAINT FORM
Please Print or Type
PERSON REGISTERING THE COMPLAINT
Mr. Ms.
Name:
(Last Name)
(First Name)
(Middle Initial)
Mailing Address:
(City)
(State)
(Zip Code)
Phone Number:
Email:
(Daytime Number)
(Evening Number)
Mr. Ms.
Patient Name:
(Last Name)
(First Name)
(Middle Initial)
Patient Date of Birth:
Your Relationship to Patient:
Signature:
Date:
NATURE OF COMPLAINT
Please check the box which best describes the nature of your complaint and provide details on the next page.
Substandard Care (e.g., misdiagnosis, negligent treatment, delay in treatment, etc.)
Prescribing Issues (e.g., excessive/under
Unlicensed Provider or Aiding/Abetting
prescribing, Internet)
Unlicensed Practice
Physician/Provider Impairment
Sexual Misconduct
(e.g., Drug, Alcohol, Mental, Physical)
Unprofessional Conduct
(e.g., breach of confidence, record alteration, fraud, misleading advertising, arrest or conviction)
Office Practice (e.g., failure to provide medical records to patient, failure to sign death certificate,
patient abandonment)
Other:
Notice:
The information included on the complaint form is requested per Section 2220 of the Business and Professions Code.
Except for the name of the physician, all information requested is voluntary, but failure to provide the requested information may
delay or prevent the investigation of your complaint. Provide as much information as possible in connection with the complaint.
The information on the complaint form will be used in part to determine whether a violation of State Law has occurred. If a
violation is substantiated, the information may be transmitted to other government agencies, including the Attorney General’s
Office.
07I-61 (Revised 9/2017)

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