Ca Board Complaint PDF Details

The Medical Board of California's Enforcement Program provides a structured way for individuals to report and address grievances against healthcare providers through the Consumer Complaint Form. This form, essential for initiating the complaint process, requires detailed information from the complainant, including the healthcare provider's full name and address against whom the complaint is filed. The process underscores the importance of including any supporting documents that can substantiate the allegations made, such as patient records, photographs, and other relevant materials. Additionally, it is crucial for complainants to complete an "Authorization for Release of Information For The Subject Of The Complaint" to ensure that a thorough investigation can be conducted. Depending on the nature of the healthcare provider's setting, different release forms might be necessary, including those specific to treatments at Kaiser facilities or other healthcare establishments. The form explicitly outlines that separate complaints must be filed for each provider and clarifies the Board's limitations regarding disputes outside its jurisdiction, like billing issues or general business practices. It sets the stage for a detailed narrative of the complaint, urging specificity about any claims of substandard care to facilitate an expedited review. Furthermore, the document details the rights of the patients or legal representatives concerning the release of medical information, highlighting the confidentiality and regulatory adherence of this process.

QuestionAnswer
Form NameCa Board Complaint
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namescomplaint form medical, how to california board complaint, how to report a doctor in california, how to file a complaint against a hospital in california

Form Preview Example

Medical Board of California

Enforcement Program

Instructions for Completing the

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815-5401

Consumer Complaint Form

Phone: (916)

263-2528

Fax: (916)

263-2435

www.mbc.ca.gov

1.Legibly print or type all information.

2.Provide the full name and address of the licensee your complaint is against. Please note that the Medical Board (Board) only handles complaints against the listed individuals on the second page. Please see the “A Consumer’s Guide to the Complaint Process” for additional information.

3.Attach a copy of any supporting documents you may have in your possession pertaining to your specific complaint; documents may include patient records, photographs, audio or video recordings, correspondence, billing statements, proof of payments, autopsy/toxicology report, police report, court documents, etc.

4.Please sign and date the complaint form.

5.Complete the “Authorization for Release of Information For The Subject Of The Complaint” (Subject is the physician or other healthcare provider you are complaining about)

6.Complete one of the following medical release forms in their entirety:

“Physician/Provider/Facility Authorization for Release of Information” (In this form you will list all treating facilities in addition to all relevant treating providers specific to your complaint. If the incident is involving a surgical procedure, it is important that you list any pre-op or post-op providers)

-OR-

Kaiser Authorization for Release of Information” (should care and treatment have been rendered at a Kaiser facility please fill out the enclosed Kaiser form and check if it’s a “northern” or “southern” facility)

***Should the patient be deceased, the person signing the release form(s) must be a legal representative as demonstrated on a durable power of attorney, death certificate, or an executor of will/estate document.

(Please enclose copy of supportive documentation).

Please Note:

You must fill out a separate complaint form for each physician or other healthcare provider you wish to file a complaint against.

The Board does not have jurisdiction over billing/fee disputes, general business practices (contracts, office policies, appointment times/duration, etc.) or personal conflicts, unless the behavior in question interferes with the safe delivery of health care. Please contact your insurance company or your physician’s or other healthcare provider’s office to resolve disputes outside of the Board’s jurisdiction.

The Board cannot award any kind of financial compensation.

Please be advised that the Board cannot assist with any coordination of patient care. Should you require assistance please contact your insurance company or medical providers.

Review the brochure, “A Consumer’s Guide to the Complaint Process”, for information about the complaint review process.

For more information visit: www.mbc.ca.gov/Consumers/Complaints/

Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs 07I-61 (Rev 09/20)

Medical Board of California

Enforcement Program

Consumer Complaint Form

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815-5401

 

Phone: (916)

263-2528

 

Fax: (916)

263-2435

www.mbc.ca.gov

COMPLAINT REGISTERED AGAINST

Check one: Physician (MD)

Podiatrist (DPM)

Midwife

Polysomnographer Research Psychoanalyst Unlicensed Provider Subject Information

Last Name

First Name

Middle Initial

Provider’s License Number

 

 

 

 

 

 

Office/Facility Name

 

 

 

 

Phone Number

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip Code

 

 

 

 

 

 

PERSON REGISTERING COMPLAINT

Last Name

 

First Name

 

Middle Initial

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

 

Phone Number

Email Address

 

 

 

 

 

 

 

 

PATIENT INFORMATION

Patient’s Name

Patient’s Date of Birth

Your Relationship to Patient

NATURE OF COMPLAINT (Check all that apply)

Quality of Care (Misdiagnosis, treatment/medication causing side effects, surgical complications, negligent care, etc.)

Office Practice (Failure to sign death certificate, failure to provide records, misleading advertising, double billing, billing for services not rendered)

Inappropriate Prescribing

Provider Impairment (Under the influence of drugs or alcohol, mental or physical impairment)

Sexual Misconduct

Unlicensed Activity (Aiding and abetting unlicensed practice, unlicensed provider)

Medical Board of California State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs 07I-61 (Rev 09/20)

DETAILS OF COMPLAINT (Attach additional pages if necessary)

State your complaint in chronological order and in detail. In addition, please include dates of treatment and list all relevant treating providers specific to your complaint. It is important that you be specific regarding any allegations of substandard care. Providing a comprehensive narrative of your complaint allows for a more expeditious review process.

Signature

Date

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs 07I-61 (Rev 09/20)

Medical Board of California

Authorization for Release of Information for the Subject of the Complaint

Enforcement Program

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815-5401

Phone: (916) 263-2528

Fax: (916) 263-2435

www.mbc.ca.gov

CHECK ALL RECORD TYPES THAT APPLY

Medical Records

Diagnostic Images

HIV/AIDS

Alcohol/Drug Abuse

Psychiatric

 

 

 

 

 

PATIENT INFORMATION

 

 

 

 

 

Patient Name

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

Date of Death (If applicable)

 

 

 

 

 

 

 

 

Medical Record Number (If known)

 

 

 

 

 

 

 

 

Control Number

 

 

 

 

 

Continued on Page 2

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs

(Rev 06/20)

Patient Name:

Page 2 of 2

I, the undersigned hereby authorize:

Physician/Provider

Street Address

City

State

Zip Code

Phone Number

Treatment Date(s)

to disclose medical records in the course of my diagnosis and treatment to the Medical Board of California, Enforcement Program, a healthcare oversight agency. This disclosure of records authorized herein is required for official use, including investigation and possible administrative and/or criminal proceedings regarding any violations of the laws of the State of California. This authorization shall remain valid for three years from the date of signature. A copy of this authorization shall be as valid as the original. I understand that I have the right to receive a copy of this authorization if requested by me. I understand that I have a right to revoke this authorization by sending written notification to the Medical Board of California at the above address. My written revocation will be effective upon receipt by the Medical Board of California but will not be effective to the extent that such persons have acted in reliance upon this Authorization. I understand that the recipient of my information is not a health plan or healthcare provider and the released information may no longer be protected by federal privacy regulations. I am signing this authorization voluntarily and understand that treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.

Patient Signature

- OR -

Legal Representative Name

Legal Representative Signature

Date

Relationship to Patient

Date

NOTE: Failure by a physician, podiatrist, or healthcare provider to provide the requested records within 15 days, or a healthcare facility within 30 days, of receipt of this request and authorization may constitute a violation of Section 2225.5 of the Medical Practice Act and may result in further action by the Board.

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs

(Rev 06/20)

Medical Board of California

 

 

Enforcement Program

Physician/Provider/Facility Authorization

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815-5401

for Release of Information

 

 

Phone: (916) 263-2528

 

 

Fax: (916) 263-2435

 

 

 

 

 

www.mbc.ca.gov

 

 

 

 

 

CHECK ALL RECORD TYPES THAT APPLY

 

 

 

Medical Records

 

Diagnostic Images

HIV/AIDS

 

Alcohol/Drug Abuse

Psychiatric

 

 

 

 

 

 

 

 

 

 

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

Patient Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Death (If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Record Number (If known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Control Number

 

 

 

 

 

 

 

 

 

I, the undersigned hereby authorize:

 

 

 

 

 

 

 

 

 

Physician/Provider/Facility

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

 

Phone Number

 

Treatment Date(s)

 

 

 

 

 

 

 

 

 

 

 

 

Physician/Provider/Facility

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

Phone Number

 

Treatment Date(s)

 

 

 

 

 

 

 

Continued on Page 2

 

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs

(Rev 06/20)

Patient Name:

Page 2 of 2

Physician/Provider/Facility

Street Address

City

State

Zip Code

Phone Number

Treatment Date(s)

to disclose medical records in the course of my diagnosis and treatment to the Medical Board of California, Enforcement Program, a healthcare oversight agency. This disclosure of records authorized herein is required for official use, including investigation and possible administrative and/or criminal proceedings regarding any violations of the laws of the State of California. This authorization shall remain valid for three years from the date of signature. A copy of this authorization shall be as valid as the original. I understand that I have the right to receive a copy of this authorization if requested by me. I understand that I have a right to revoke this authorization by sending written notification to the Medical Board of California at the above address. My written revocation will be effective upon receipt by the Medical Board of California but will not be effective to the extent that such persons have acted in reliance upon this Authorization. I understand that the recipient of my information is not a health plan or healthcare provider and the released information may no longer be protected by federal privacy regulations. I am signing this authorization voluntarily and understand that treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.

Patient Signature

- OR -

Legal Representative Name

Legal Representative Signature

Date

Relationship to Patient

Date

NOTE: Failure by a physician, podiatrist, or healthcare provider to provide the requested records within 15 days, or a healthcare facility within 30 days, of receipt of this request and authorization may constitute a violation of Section 2225.5 of the Medical Practice Act and may result in further action by the Board.

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs

(Rev 06/20)

Medical Board of California

Kaiser Authorization for Release of Information

Enforcement Program

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815-5401

Phone: (916) 263-2528

Fax: (916) 263-2435

www.mbc.ca.gov

CHECK ALL RECORD TYPES THAT APPLY

Medical Records

Diagnostic Images

HIV/AIDS

Alcohol/Drug Abuse

Psychiatric

 

 

 

 

 

PATIENT INFORMATION

 

 

 

 

 

Patient Name

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

Date of Death (If applicable)

 

 

 

 

 

 

 

 

Medical Record Number (If known)

 

 

 

 

 

 

 

 

Control Number

 

 

 

 

 

Continued on Page 2

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs

(Rev 06/20)

Patient Name:

Page 2 of 2

I, the undersigned hereby authorize:

Physician/Provider/Facility: Kaiser Permanente (Northern Facilities)

Physician/Provider/Facility: SCPMG/Kaiser Foundation Hospital (Southern Facilities) Treatment Date(s)

to disclose medical records in the course of my diagnosis and treatment to the Medical Board of California, Enforcement Program, a healthcare oversight agency. This disclosure of records authorized herein is required for official use, including investigation and possible administrative and/or criminal proceedings regarding any violations of the laws of the State of California. This authorization shall remain valid for three years from the date of signature. A copy of this authorization shall be as valid as the original. I understand that I have the right to receive a copy of this authorization if requested by me. I understand that I have a right to revoke this authorization by sending written notification to the Medical Board of California at the above address. My written revocation will be effective upon receipt by the Medical Board of California but will not be effective to the extent that such persons have acted in reliance upon this Authorization. I understand that the recipient of my information is not a health plan or healthcare provider and the released information may no longer be protected by federal privacy regulations. I am signing this authorization voluntarily and understand that treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.

Patient Signature

- OR -

Legal Representative Name

Legal Representative Signature

Date

Relationship to Patient

Date

NOTE: Failure by a physician, podiatrist, or healthcare provider to provide the requested records within 15 days, or a healthcare facility within 30 days, of receipt of this request and authorization may constitute a violation of Section 2225.5 of the Medical Practice Act and may result in further action by the Board.

Medical Board of California

State of California | Business, Consumer Services, and Housing Agency | Department of Consumer Affairs

(Rev 06/20)

How to Edit Ca Board Complaint Online for Free

Filling in the complaint medical board document is a breeze using our PDF editor. Try out these particular steps to create the document right away.

Step 1: Click on the "Get Form Here" button.

Step 2: At the moment you're on the form editing page. You can edit and add text to the form, highlight words and phrases, cross or check certain words, insert images, put a signature on it, delete needless fields, or remove them completely.

The next few segments will help make up your PDF form:

stage 1 to completing how to report a doctor in california

Complete the COMPLAINT REGISTERED AGAINST, Check one Physician MD, Podiatrist DPM, Midwife, Polysomnographer Research, First Name, Middle Initial, Providers License Number, Phone Number, Subject Information Last Name, OfficeFacility Name, Street Address, City, PERSON REGISTERING COMPLAINT, and Last Name fields with any data that are demanded by the system.

Finishing how to report a doctor in california part 2

The system will ask you for particulars to instantly fill up the segment Street Address, City, Phone Number, Email Address, PATIENT INFORMATION, Patients Name, Your Relationship to Patient, State, Zip Code, Patients Date of Birth, NATURE OF COMPLAINT Check all that, Quality of Care Misdiagnosis, Office Practice Failure to sign, and for services not rendered.

stage 3 to finishing how to report a doctor in california

The Inappropriate Prescribing, Provider Impairment, Under the influence of drugs or, Sexual Misconduct, Unlicensed Activity Aiding and, Medical Board of California, and State of California Business box will be your place to put the rights and responsibilities of either side.

how to report a doctor in california Inappropriate Prescribing, Provider Impairment, Under the influence of drugs or, Sexual Misconduct, Unlicensed Activity Aiding and, Medical Board of California, and State of California  Business fields to fill out

Review the areas DETAILS OF COMPLAINT Attach and next fill them in.

DETAILS OF COMPLAINT Attach in how to report a doctor in california

Step 3: Press the "Done" button. Next, you may transfer the PDF document - download it to your electronic device or forward it via email.

Step 4: Make copies of your form. This may protect you from possible future issues. We cannot check or share your details, so be assured it's going to be protected.

Watch Ca Board Complaint Video Instruction

Please rate Ca Board Complaint

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .