Health Care Provider Complaint Form

This information MUST be completed to investigate your complaint, as we correspond via

U.S. mail. Incomplete forms CANNOT be processed.

Florida Statutes 456.073, Disciplinary proceeding: (1) The department, for the boards under its jurisdiction, shall cause to be
investigated any complaint that is filed before it if the complaint is in writing, signed by the complainant, and legally sufficient. If an
investigation of any subject is undertaken, the Department will furnish to the subject or the subject's attorney a copy of the complaint or
document that resulted in the initiation of the investigation

Health Care Provider Information:

Name:
Last First M.I. Profession License Number

Address:
Number & Street City State Zip

Phone number(s): Website:

Complainant Information:

Agency/Company Name (If applicable): _________________________________________________________________

Your Name:
Last First M.I.

Address:
Number & Street City State Zip

Phone Number: ______________________ Email: ______________________________________________________

Patient Information:
Please complete this section if you are not the patient.

Name:
Last First M.I.

Address:
Number & Street City State Zip

Phone Number: Date of Birth: ___________________________

Your relationship to the patient:

Parent Son/Daughter Spouse Brother/Sister Friend Legal Guardian Other

Please provide documentation indicating your appointment as the legal authority/guardianship or personal representative.

The Department does not investigate complaints regarding the amount charged for a procedure,
broken or missed appointments, customer service, bedside manner, rudeness, professionalism
or personality conflicts.

Page 1 of 4
If the incident involved criminal conduct, contact local law enforcement. Have you contacted local law enforcement?

Yes No

If Yes, Name of Contact: __________________ Date: ___________ Case Number: _______________________

Agency Name:________________________________ ___

Provide a complete description of the complaint/report.

Include facts, details, dates, locations, etc. (who, what, when and where)
Attach additional sheets if necessary.

Please make and attach copies of medical records, correspondence, contracts and any other documents
that will help support your complaint. Failure to attach records will delay the investigation.

Date of Incident: _____________________________

The complaint form must be signed and returned to the Department.

Signature: Date:
(Required to file complaint)

You may scan and return the form You may mail the form to: You may fax the form to:
via email to:
Consumer Services Unit 850-488-0796
[email protected] 4052 Bald Cypress Way, Bin C-75
Tallahassee, FL 32399-3275
Page 2 of 4
 AUTHORIZATION FOR RELEASE OF PATIENT
INFORMATION

To: Any and All Treating Health Care Practitioners or Facilities:

This authorization meets the requirements of the Health Insurance Portability and Accountability Act of
1996 (HIPAA Privacy Law) found at 45 CFR, Part 164.

This document authorizes any and all licensed health care practitioners, including but not
limited to: physicians, nurses, therapists, social workers, counselors, dentists, chiropractors,
podiatrists, optometrists, hospitals, clinics, laboratories, medical attendants and other
persons who have participated in providing any health care or service to me, to discuss any
communication, whether confidential or privileged, and to provide full and complete patient
reports and records justifying the course of treatment including but not limited to: patient
histories, x-rays, examination and test results, HIV, mental health, drug abuse treatment,
psychiatric and psychological records, reports or information prepared by other persons
that may be in your possession and all financial records, to the Department of Health (or any
official representative of the Department) pursuant to Section 456.057, Florida Statutes.
This document provides full authorization to the Department of Health (or any official
representative of the Department) to use any of the aforementioned reports and information
for reproduction, investigation or other use for licensure or disciplinary actions and civil,
criminal or administrative proceedings, as needed by the Department and may be subject to
re-disclosure by the recipient and may no longer be protected by the federal privacy laws and
regulation.
By signing below, the patient understands, acknowledges and authorizes the Department
to release their identity and medical records to law enforcement and other regulatory
agencies in appropriate circumstances at the Department's discretion.

A photocopy of this document is as sufficient as the original.

I understand that this authorization may be revoked upon my written request except to the extent that
action has already been taken on this authorization.

Patient Name (Print): Signature:

D.O.B.: SSN: Date:

Name of Authorized Person Other than Patient (Print):

Signature of Authorized Person Other than Patient:

Witness Name (Print): Witness Signature:

DOH USE ONLY

Reference Number

__________

Page 3 of 4
 Unlicensed Activity
Only complete this page if your complaint is for 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:________________________________________________________________

Name: ________________________________ Address:________________________________________________________________

Names of other subjects/licensees at the same location or business: ___________________________________________________

______________________________________________________________________________________________________________

Page 4 of 4