Health Care Provider Complaint Form Page 2
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4If the incident involved criminal conduct contact local law enforcement; have you contacted local law enforcement?
Yes
No
If yes, name of contact: _____________________________, date: __________, case number: ____________
Agency Name: ______________________________________________________________________
Providers Who Treated You After the Incident (Use a separate sheet if necessary)
Name: ______________________________________________________________________________________
Last
First
M.I.
Address: ____________________________________________________________________________________
City
State
Number & Street
Zip
Name: ______________________________________________________________________________________
Last
First
M.I.
Address: ____________________________________________________________________________________
City
State
Number & Street
Zip
Provide a complete description of the complaint/report.
Include facts, details, dates, locations, etc. (Who, what, when and where)
Attach copies of medical records, correspondence, contracts and any other documents that will help
support your complaint. Failure to attach records will delay the investigation. (Attach additional sheets
if necessary).
Florida Statutes 837.06, False Official Statements: Whoever knowingly makes a false statement in
writing with the intent to mislead a public servant in the performance of his or her official duty shall be
guilty of a misdemeanor of the second degree.
Signature: __________________________________________________________________ Date: _______________
(
Required to file complaint)
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Parent category: Legal