West Virginia Board of Acupuncture

Complaint Committee of the
West Virginia Board of Acupuncture
179 Summers Street, Suite 711
Charleston, WV 25301-2122
(304) 558-1060

NOTE: This form also available in Adobe Acrobat(.pdf) format here

Complaint questionnaire

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_____________________________________________

    Address________________________________________________________

    _______________________________________________________________

    Phone__________________________________________________________

2.  Complaint Against______________________________________________

    Address________________________________________________________

    _______________________________________________________________

     Phone_________________________________________________________

 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

    _______________________________Date