Complaint Form printable pdf download

Complaint Form

Revised 7/2015

This form may be used to file a complaint with the Oregon Medical Board regarding care

provided by the following medical practitioners: Medical Doctors, Doctors of Osteopathic

Medicine, Podiatrists, Physician Assistants, and Acupuncturists.

Please note: the Oregon

Medical Board does not have jurisdiction over Nurses, Nurse Practitioners, Medical

Assistants, or medical office staff.

A complaint may also be filed without using this form by submitting a detailed written

letter to the Board summarizing your complaint.

If you chose to use this Complaint Form, please complete the following information. Please

attach any photocopies of documents, including medical records if available, that are

pertinent to your complaint. State in detail all facts which you believe justify your complaint.

Use additional paper as necessary.

1) Name of Complainant (Your Name):

First: __________________________ Middle: ___________ Last: ____________________

Address: __________________________________________________________________

City: ___________________________________ State: _______ Zip: __________________

Date of birth: ____________ Relationship to Patient:______________________________

Home Phone: ________________ Cell Phone: ________________ Fax: _______________

E-mail Address: ____________________________________________________________

2) Name of Patient (if not complainant above):

First: __________________________ Middle: ___________ Last: ____________________

Address: __________________________________________________________________

City: ___________________________________ State: _______ Zip: __________________

Date of birth: ____________ Phone:_______________________________

3) Complaint Against:

Doctor of

Medical

Osteopathic

Physician

Doctor

Medicine

Podiatrist

Assistant

Acupuncturist

Provider Name- First: __________________ Middle: ________ Last: _________________

Address: __________________________________________________________________

City: ___________________________________ State: _______ Zip: __________________

License Number (if known): _________________ Phone: ___________________________

Oregon Medical Board| 1500 SW 1st Ave, Suite 620 | Portland, Oregon | 97201

971.673.2700 or 877.254.6263 |

Complaint Form