Submit a Complaint

Submit Complaint Against

Full Name of Licensee to submit complaint against

Address

Licensee Number

Profession

License Type

Name of Person Affected

Full Name

Date of Birth

Mailing Address

Phone Number

Fax Number

Name of Person Submitting Complaint (if different from above)

Full Name

Mailing Address

Phone Number

Fax Number

Complaint Details

Be as clear, complete, and concise as possible. Incomplete information may delay the investigation of your complaint. Please be advised that once the Department of Health is in receipt of a complaint, we will move forward with our established process and the complaint cannot be rescinded.

I hereby declare and affirm under the pains and penalties of perjury that the information on this form has been reviewed by me, and is true, and accurate to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.