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Confidential
State Medical Board of Ohio
On-Line Complaint Form
For complaints about a
physician, osteopathic physician, podiatric physician, physician assistant,
anesthesiologist assistant, massage therapist, cosmetic
therapist, acupuncturist, mechanotherapist or naprapath |
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Please use this form to file a
confidential complaint with the Medical Board.
Fill out the entire form below. When you have finished, please click the Submit
button to send your information to our Public Inquiries department.
If you would like a downloadable version of this form that
may be
completed off line and mailed or faxed to our office,
click here.
If you would like to review
the Board's Consumer's Guide, which contains information
about filing complaints and the complaint process,
prior to filing your complaint,
you may
access the Consumer's Guide by clicking
here.
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Date: |
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Your Name: |
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Your Address: |
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City: |
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State: |
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Zip Code: |
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Home Phone: |
Your phone number will
speed up our handling of your complaint, especially if
the complaint involves access to your medical records. |
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Work Phone: |
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Email:
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(OPTIONAL)
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Patient
Information |
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Patient Name: |
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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. |
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Patient's Date of Birth: |
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Patient's Social Security Number: |
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Please list the full name, address and phone number of
the health care provider(s) you wish to report to the
Medical Board.
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Provider #1 |
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Name: |
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Address |
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Phone Number |
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Provider #2 |
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Name: |
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Address: |
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Phone Number: |
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If there are more than two, please list the additional
providers and their addresses and phone numbers in the
box below. |
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Additional providers: |
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Date the incident occurred: |
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In the box
below, please describe your concerns regarding your
health care professional or staff. |
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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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