Complete and return the Authorization Form only if your complaint involves a health care professional.
Exact date: If you do not know the exact date, make as close an estimate as possible.
Evidence: Attach copies of any relevant documents or evidence such as contracts, photographs, medical records, billing statements, etc.
After filing: It is very important that you do not dispose of any information or evidence even after you have filed a complaint.
Other agency or court: If your complaint is, or has been, under consideration by another agency or court please provide that information.
| Question | Answer |
|---|---|
| Form Name | Form 102DLSC |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 12 min |
| Edition | Rev 10/18 |
| Issuing agency | Wisconsin Department of Safety and Professional Services |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | 102DLSC, #102DLSC, DSPS complaint form, Wisconsin DSPS complaint, Complaint Form |
| Official source | Form 102DLSC (Rev 10/18), Wisconsin Department of Safety and Professional Services |
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