Healthcare Professionals Reporting Form

Resources & Information

Healthcare Professionals Reporting Form

Healthcare professionals should use this form to report licensee misconduct or substandard care, including mandatory reports about licensee sexual misconduct or prescribing misconduct as specified in NCGS 90-5.4.

Before submitting a complaint/report, be sure to gather addresses and contact information for anyone the Board may need to follow up with (e.g. the licensee being reported, potential witnesses, others involved). Photos, documents or other files related to the incident may be uploaded and sent to the Board with your report.

indicates required field

Please provide your contact information:

First Name:

Middle Name:

Last Name:

Mailing Address:

City

State

Zipcode

Primary Phone Number:

Other Phone Number:

Your Email Address:

Verify Email Address:

Information about the licensee you are reporting:

Licensee's First Name:

Middle Name:

Licensee's Last Name:

Licensee's practice address or practice name:

City

State

Zipcode

Licensee's Telephone #:

Reason for Report

Please provide a description of the issue that prompted your report. Include the names of any patients or other individuals involved:

Where did this event occur? Please list full name of medical practice or hospital.

When did this event occur? Please list specific dates, if known.

If you are aware of other potential witnesses, please provide names and contact information, if known.

Has this incident been reported to any other entity or law enforcement?

No Yes

If yes, please report the agency name and contact person.

Attachments
(medical records, correspondence, etc.)

Attachment 1

Attachment 2

You will receive an auto reply to the email entered above. If you do not receive this email, your submission was not received.

You may contact the Investigations Department if you have any issues or questions.