File Complaint Against A Dentist Details

The Form Inf 10A is an information return that must be filed by every person or entity in India who received a payment or payments of Rs.10,00,000 (ten lakhs) or more during the financial year. This form is used to report all payments made to any payee, regardless of the amount. The filing of this form is mandatory for both residents and non-residents in India. Penalties may be imposed for failure to comply with this requirement. This article will provide a brief overview of the Form Inf 10A and explain who must file it, what information must be reported, and the consequences of not doing so.

Here, you can see quite a few particulars about form inf 10a PDF. It is worth taking a few minutes to learn this before starting filling in your form.

QuestionAnswer
Form NameForm Inf 10A
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesbureau of dental board of california complaint intake unit form example, dental board of california complaint form, california complaint dental board, california dental board complaints

Form Preview Example

Dental Board of California

2005 Evergreen Street, Suite 1550, Sacramento, California 95815 P (916) 263-2300 | F (916) 263-0873 | www.dbc.ca.gov

CONSUMER COMPLAINT FORM

PLEASE PRINT OR TYPE

COMPLAINT REGISTERED AGAINST

Name:

Name of Dental Office:

Address:

City:

State:

Zip Code:

Office Phone Number:

Person Registering Complaint

Mr.

Name:

 

 

 

Relationship to Patient:

Mrs.

 

 

 

 

 

Ms.

 

 

 

 

 

 

 

 

 

Home Phone Number:

Address:

 

 

 

 

 

 

 

 

 

Work Phone Number:

City:

 

State:

Zip Code:

 

 

 

 

 

Male

Patient’s Date of Birth:

Patient Name:

 

Female

 

 

Legal authority to act on patient’s behalf?

Has patient been examined or treated by another dentist for this same complaint?

YES

If yes, please provide full names and addresses on the Supplemental Complaint Information

 

form.

 

NO

DESIRED OUTCOME OF THIS COMPLAINT

DETAILS OF COMPLAINT

Dates of Visits:

State your complaint in detail:

NOTICE: As much information as possible should be provided, in addition to any supporting documents pertaining to your specific complaint. Failure to provide sufficient information or documentation may prevent or delay the review of your complaint. The information will be used to determine whether a violation of law has occurred. If a Dviolation is substantiated, the information may be transmitted to other governmental agencies, including the Attorney General’s Office. The Dental Board of California does not have jurisdiction over fee disputes or office

business procedures.

DO NOT WRITE IN

THIS SPACE

Signature________________________________________ Date_____________________________

ENF-10A (01/11)

Dental Board of California

2005 Evergreen Street, Suite 1550, Sacramento, California 95815 P (916) 263-2300 | F (916) 263-0873 | www.dbc.ca.gov

SUPPLEMENTAL COMPLAINT INFORMATION

PLEASE PROVIDE THE NAME, ADDRESS, TELEPHONE NUMBER AND DATE OF VISIT TO ANY OTHER DENTISTS YOU HAVE SEEN SINCE BEING TREATED BY THE SUBJECT OF YOUR COMPLAINT.

1.

 

 

SUITE #

 

 

 

 

PHONE #

DATE(S)

2.

 

 

 

 

SUITE #

 

 

 

 

PHONE #

DATE(S)

3.

 

 

 

 

SUITE #

 

 

 

 

PHONE #

DATE(S)

4.

 

 

 

 

SUITE #

 

 

 

 

PHONE #

DATE(S)

ENF-10B (01/11)

Dental Board of California

2005 Evergreen Street, Suite 1550, Sacramento, California 95815 P (916) 263-2300 | F (916) 263-0873 | www.dbc.ca.gov

Authorization for Release of Dental/Medical Patient Records

Patient Name:

 

Date of Birth:

AUTHORIZATION TO RELEASE INFORMATION: I, the undersigned, authorize any physician, dentist, medical practitioner, hospital, clinic or other dental or dental related facility having records (original and/or electronic) available as to diagnosis, treatment and prognosis with respect to any dental or medical condition and/or treatment of me (or the patient) to release to the Dental Board of California or any Board representatives, related local, state and federal governmental agencies, including but not limited to, investigators and legal staff.

I understand that this information will be maintained in confidence, and will be used solely in conjunction with any investigation and possible legal proceeding regarding any violations of California laws and regulations. I further agree to allow the Board, Board representatives and related governmental agencies, to process and possibly file other charges based on my complaint.

I also understand that the subject of my complaint (the dentist or dental auxiliary I am complaining about) may receive a copy of my complaint and records pursuant to the Administrative Procedures Act and the Information Practices Act.

I agree that a photocopy of this Authorization shall be as valid as the original. This Authorization shall remain valid until the Dental Board of California or other authorized Government Agency completes its review and the proceedings arising out of the investigation.

I understand that I have a right to receive a copy of this authorization if requested by me. Patient/Guardian

Signature:______________________________Date:_______________

Attach written proof of authorization to act on patient’s behalf.

This release is in compliance with the requirements of Civil Code § 56.11.

ENF-10C (01/11)

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