DOH-3867 (2/20) p 1 of 4
Please print clearly and complete all sections of this form and mail to:
Office of Professional Medical Conduct
Central Intake Unit
Riverview Center
150 Broadway- Suite 355
Albany, NY 12204-2719
(This form must include your original signature)
All reports of misconduct are kept confidential and are protected from disclosure according to New York State Public Health Law, Sections
230(10)(a)(v) and 230(11)(a). Any person who reports or provides information to the Board for Professional Medical Conduct in good faith, and
without malice, shall not be subject to an action for civil damages or other relief as the result of making the report according to Section 230(11)(b).
See instructions on page 4 before completing this form.
INFORMATION ABOUT YOU
Name
Last First MI
Address
House number & Street Name City State Zip Code
Telephone ( ) – ( ) –
Day time number Evening Number
YOUR COMPLAINT REGARDING A PHYSICIAN OR PHYSICIAN ASSISTANT
Physician/Physician Assistant Name
Last First MI
Address
Number & Street Name City State Zip Code
Telephone ( ) –
INFORMATION ABOUT THE PATIENT(S)
** You may add additional patient names on a separate sheet of paper.
Patient(s) Name
Last First MI
Date of Birth / /
Month Day Year
DETAILS OF YOUR COMPLAINT
Describe your complaint as completely as possible. Please sign and date form.
When did this happen?
Where did this happen?
Have you filed a Complaint with anyone else? Yes No
If Yes, with whom?
Were there any witnesses?
You may add additional witness names on a separate sheet of paper.
Witness Name
Last First Name MI
Witness Name
Last First Name MI
EXPLAIN YOUR COMPLAINT
NEW YORK STATE DEPARTMENT OF HEALTH
Office of Professional Medical Conduct
Complaint Form