|This complaint form
may only be used to file a complaint against an MD. If you wish to file a complaint against a health provider other than an MD, please check here for a list of other licensing
agencies; find the type of health care provider you wish to file a complaint against and;
contact the corresponding licensing agency.
||Complete the enclosed complaint
form, treatment information form and medical records release form.
||Provide the full name of the
MD that you wish to file a complaint against. You may name more than one doctor per complaint.
||Complete a detailed narrative
statement outlining your complaint in chronological order.
||Provide the names of all other
health care providers who have evaluated or treated the patient for the
same medical condition, either before or after the subject physician,
including physicians, hospitals and emergency rooms, urgent case centers
and radiology (x-ray) facilities. Please provide the dates of
treatment for each health care provider.
||Provide the full name, address
and daytime telephone number of any witnesses that can provide evidence to
support your complaint, as well as, a brief statement about what evidence
the witness is able to provide.
||Provide a copy of any supporting
documents you have in your possession pertaining to your specific
complaint, i.e., copies of medical records, explanation of Medicare
Benefits (EOMB) or other insurance payments, billings, correspondence,
etc. Please do not provide the Board with your original documents.
|Please be advised,
the Board's complaint files and records are confidential investigative
materials, and by law, and are not available to you. Arizona
Revised Statutes (A.R.S.) �32-1451.01. Ensure you have all of your
complaint information available prior to the commencement of
completing your complaint. Complete and submit your complaint
in one session. Currently we do not support the on-line
capability to retrieve and edit a complaint once it has been
||Click here to
download/print a blank Complaint form; or
Click here to file a Complaint