Submit a Complaint | State Medical Board of Ohio

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	State Medical Board of Ohio

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submit a complaint

Before submitting a complaint, please read about how to submit a complaint for complete details.

	Your Information
Date
Your Name
Your Address
City
State
Zip Code
Home Phone
	Your phone number will speed up our handling of your complaint, especially if the complaint involves access to your medical records.
Work Phone
Email

	Optional

	Patient Information
Patient Name
Patient's Date of Birth
	The Board is requesting that you provide the patient's date of birth and social security number to ensure that the patient is properly identified if a subpoena is sent to the health care provider for copies of the patient's records, as authorized by Section 4731.22(F)(3), ORC.
Patient's Social Security Number

	Provider #1
	Please list the full name, address and phone number of the health care provider(s) you wish to report to the Medical Board.
Name
Address
Phone Number

	Provider #2
Name
Address
Phone Number

Additional providers
	If there are more than two, please list the additional providers and their addresses and phone numbers.
Date the incident occurred

	Please describe your concerns regarding your health care professional or staff.
nature of complaint

	Prior to submitting the form, please review the information you have provided. Check this box to indicate that you have completed entering your complaint information

	When you are satisfied that the form is complete, press the Submit button to send your complaint to our Public Inquiries Department.

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30 E. Broad Street, 3rd Floor, Columbus, Ohio 43215-6127 ph: 614-466-3934 fx: 614-728-5946