Form Inf 10A PDF Details

When individuals face issues with dental services that potentially breach legal standards or ethical practices, the Consumer Complaint Form INF 10A provided by the Dental Board of California stands as a pivotal document to formally voice concerns and seek resolution. Governed by the Business, Consumer Services, and Housing Agency and overseen by Governor Gavin Newsom's administration, this form embodies a structured approach towards lodging complaints against dental professionals or establishments. It covers essential details including the identification of the dental office in question, the complainant's information, a descriptive account of the grievance, and the desired outcome of the complaint process. Importantly, it emphasizes the need for providing comprehensive information and any pertinent documents to support the case, underlining the significance of thoroughness for the effective processing and review of complaints. Additionally, it sets clear boundaries on its jurisdiction, explicitly excluding fee disputes or office business procedures from its purview. For cases requiring further substantiation, the form allows for the inclusion of details about consultations with other dentists subsequent to the incident. Moreover, it includes an authorization section for the release of medical or dental records, crucial for a detailed investigation into the complaint, ensuring confidentiality and a lawful process in handling the collected information. This form not only facilitates accountability within the dental care sector but also underscores the proactive measures individuals can take to address issues related to their dental health services.

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

Form Preview Example

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

. I

DENTAL BOARD OF CALIFORNIA

2005 Evergreen St., Suite 1550, Sacramento, CA 95815

P (916) 263-2300 | F (916) 263-2140 | www.dbc.ca.gov

CONSUMER COMPLAINT FORM

PLEASE PRINT OR TYPE

COMPLAINT REGISTERED AGAINST

 

 

 

 

 

 

 

 

 

 

 

Name of Dental Office:

 

Name:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

City:

 

State:

Zip Code:

Office Phone Number:

 

PERSON REGISTERING COMPLAINT

 

 

 

 

Mr.

Name:

 

 

Relationship to Patient:

Mrs.

 

 

 

 

 

 

Ms.

 

 

 

 

 

 

 

 

 

 

Home Phone

Number:

 

Address:

 

 

 

 

 

 

City:

 

State:

Zip Code:

Work Phone Number:

 

 

 

 

 

 

 

 

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

NO

If yes, please provide full names and addresses on the back of this form.

 

 

 

DESIRED OUTCOME OF THIS COMPLAINT

DETAILS OF COMPLAINT

Dates of Visits:

State your complaint in detail:

DNOTICE: 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 violation 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-10 (12/17)

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

DENTAL BOARD OF CALIFORNIA

2005 Evergreen St., Suite 1550, Sacramento, CA 95815

P (916) 263-2300 | F (916) 263-2140 | 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-10 (12/17)

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

DENTAL BOARD OF CALIFORNIA

2005 Evergreen St., Suite 1550, Sacramento, CA 95815

P (916) 263-2300 | F (916) 263-2140 | 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 (12/17)

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part 1 to completing dental complaint board

Type in the demanded data in the field Has patient been examined or, YES, DESIRED OUTCOME OF THIS COMPLAINT, DETAILS OF COMPLAINT, Dates of Visits, and State your complaint in detail.

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You can be required to provide the details to let the platform prepare the field NOTICE As much information as, Signature, Date, and ENF.

stage 3 to completing dental complaint board

Through box PHONE, PHONE, PHONE, SUITE, DATES, SUITE, DATES, SUITE, DATES, and SUITE, state the rights and responsibilities.

dental complaint board PHONE, PHONE, PHONE, SUITE, DATES, SUITE, DATES, SUITE, DATES, and SUITE fields to fill

Look at the sections PHONE, SUITE, DATES, and ENF and next complete them.

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