Complaint Form (Page 2 of 3) in pdf

Complaint Form Page 2

Complaint Form

Revised 7/2015

4) Specific Information about your Complaint:

a. What are the dates that the provider in question cared for you/patient?

b. Have you contacted the provider directly about your complaint?

Yes

If so, what action (if any) was taken?

c. Did any other provider(s) treat you/patient after the alleged incident?

Yes

If YES, please specify names and address of other providers:

d. Have you/patient been treated at any hospitals or urgent care facilities related to this

complaint?

Yes

If YES, please identify the facility name and address as well as the date of treatment

e. Have you filed this complaint elsewhere?

Yes

If yes, where?

What action was or is being taken?

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

971.673.2700 or 877.254.6263 |

Complaint Form Page 2