Complaint Form

Person Submitting This Complaint


Name of Person Submitting This Complaint:
Street Address:
City:	State:	Zip:
Daytime Phone:	Evening Phone:	Email:

Patient Details


Name of Patient Involved in the Incident Which Gives Rise to This Complaint:	Date of Birth of Patient Involved in the Incident Which Gives Rise to This Complaint:

Complaint Details


Name of Physician/Physician Assistant About Whom You Are Complaining:
Place (Hospital/Clinic, etc.) Where the Incident Giving Rise to This Complaint Occurred:	Date of the Incident Giving Rise to This Complaint:
Please describe the conduct about which you are complaining. It is important to be as specific as is reasonably possible. If you are in possession of medical records or other documents which support your allegations, you may provide them to the board by uploading them as indicated below, or by mailing them to the board at North Dakota Board of Medicine, 4204 Boulder Ridge Rd, Suite 260, Bismarck, ND, 58503. Note: The character limit for this field is 4000 characters.
You may upload a file by clicking the button below. Drop file(s) here or Uploaded File(s) Click here for recommendations on uploading files.
I hereby declare that all of the information I have provided with this form is true and correct.