Health Care Provider Complaint Form Page 4
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4Unlicensed Practice
Please fill out this form with information regarding individuals engaging in unlicensed activity.
What is your relationship to the subject? ______________________________________________________________
How did you become aware of the alleged unlicensed practice? ____________________________________________
When did you become aware of the alleged unlicensed practice? ___________________________________________
Location of alleged unlicensed practice: _______________________________________________________________
Time and date of treatment or incident: ________________________________________________________________
If payment was made, how was subject paid? __________________________________________________________
Does the subject or subject's business accept Medicaid? _________________________________________________
Does the subject or subject's business accept Medicare? _________________________________________________
Physical description of subject:
Race: _______
Sex: ____________
Height: __________
Weight: ________
Eye Color: _______
Description of Vehicle:
Year: ________
Make: _____________
Model: ____________
Tag No: _______________
Color: _______
Names and addresses of patients/victims/witnesses aware of your complaint:
Name: _______________________________________ Address: ______________________________________________________________________
Name: _______________________________________ Address: ______________________________________________________________________
Names of other subjects/licensees at the same location or business: _________________________________________
_________________________________________
Please return completed complaint form to:
Consumer Services Unit
4052 Bald Cypress Way, Bin C-75
Tallahassee, FL 32399-3275
Email:
mqa.consumerservices@flhealth.gov
Fax: (850) 488-0796
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Parent category: Legal