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Name of Person Submitting This Complaint:
Address of Person Submitting This Complaint
DISTRICT OF COLUMBIA
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.
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I hereby declare that all of the information I have provided with this form is true and correct.
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