NOTE: This form also available in Adobe Acrobat(.pdf) format here
Please complete the following information concerning your complaint. Please attach any photocopies of documents, including medical recordsif available, that are pertinent to your complaint. State in detailall facts which you believe justify your complaint. If possible,state whether the information is within your personal knowledge, and if not, the source or sources of the information.
Please type or print in English.
1. Name of Complainant_____________________________________________
2. Complaint Against______________________________________________
3. Additional Information Required:
a. What is the date the practitioner cared for you?__________
b. Did any individual(s) treat you after the alleged incident? ____
If yes, please specify name(s) and address(es)_________________
(use additional sheets if necessary)
c. Were you an inpatient or outpatient of any health care institution after or during the alleged incident? _________________________
If yes, please specify name(s) and address(es) _______________
d. Have you contacted the practitioner about your complaint? ____
What action was taken?________________________________________
e. Have you filed this complaint elsewhere?__________________
If yes, please specify_________________________________________
What action was or is being taken?_____________________________
f. If necessary, do you consent to the release of medical records? ___
Please describe your complaint in detail on an attached sheet.
PLEASE NOTE: In order to insure procedural due process, it will benecessary that we forward this complaint to the practitioner inquestion to be of assistance to you. YOUR SIGNED COMPLAINT IS A MATTER OF PUBLIC RECORD.
I certify that the above information is true to the best of my knowledge. I further state that I will voluntarily appear and testify to the facts in this complaint if called upon by the West Virginia Board of Acupuncture.
______________________________Signature of Complainant