helping to ensure quality health care for the citizens of north dakota
Name of Person Submitting This Complaint:
Address of Person Submitting This Complaint
ARMED FORCES AMERICAS
ARMED FORCES EUROPE
ARMED FORCES PACIFIC
DIST OF COLUMBIA
Out of Country
PRINCE EDWARD IS
Name of Physician/Physician Assistant About Whom You Are Complaining:
Name of Patient Involved in the Incident Which Gives Rise to This Complaint:
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, 418 E. Broadway, Suite 12, Bismarck, ND, 58501.
The character limit for this field is 4000 characters.
Your complaint has exceeded the maximum character limit of 4000. Please edit your complaint and consider uploading a file if you need to provide additional information.
You may upload a file by clicking
for recommendations on uploading files.
I hereby declare that all of the information I have provided with this form is true and correct.
Find a Practitioner/Verify License Status
File a Complaint
Change of Address
Board Member Login
State of North Dakota
©2012 North Dakota Board of Medicine. All rights reserved.