Department Of Public Health Petition Form
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4Department of Public Health
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Petition Form
Please fill out and return to:
State of Connecticut
Department of Public Health
Practitioner Investigations Unit
410 Capitol Avenue, MS#12HSR
P.O. Box 340308
Hartford, CT 06134-0308
Petitioner/Complainant
Name:
DOB:
Address:
Telephone Numbers: Home
Work
Relationship to patient complained about:
self
parent
spouse
son/daughter
Other* (please explain)
*If Legal Guardian please provide court documents
Patient information (complete this section if Patient is not the same as Petitioner)
Name:
Address:
DOB:
Telephone Numbers:
Respondent/Healthcare Provider (subject of the complaint)
Name:
Practice Address:
Profession/specialty (i.e. physician/cardiology, dentist/general)
Telephone Number:
PLEASE INDICATE NATURE OF YOUR COMPLAINT
Quality of care
Unlicensed practice
Unsanitary conditions
Substance abuse
Failure to release patient records
Other
Sexual contact with patient
Insurance fraud
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Parent category: Legal