Complaint Checklist
Please review the complaint checklist below and ensure you have all necessary information before proceeding.
Contact information for person filing complaint
Your full name, address, daytime telephone number and your email address.
Patient Contact information
Patient name, their date of birth, and the relationship to the patient.
Practitioner/Respondent Information
- Practitioner’s full name
- Their license type (MD, DO, PA, LP, AA, or *NP)
- Their primary area of practice (i.e., Cardiology, Neurology, etc.)
- Their specialty (i.e., Congenital heart specialist, Epilepsy)
- Their phone number and practice location
Incident information
Concise account of your major concern related to the licensee listed on your complaint form along with a general event timeline. Specific information needed includes:
- Date or timeframe of occurrence
- Full name and address of practice or hospital where the event occurred
Medical Records of Relevant Providers
Names, addresses, phone/fax numbers for any other health care provider, facility, clinic, or hospital you reference in the complaint.
Please Note:
If your complaint will reference multiple health care providers, facilities, clinics, or hospitals where you (or the patient) received medical care related to the complaint, you MUST provide the names, addresses and date(s) of services of EACH facility and/or practitioner that treated you.
*If you have a complaint regarding only a Nurse Practitioner, please contact the North Carolina Board of Nursing at 919-782-3211. Website: www.ncbon.com.
