Please complete the following information concerning your complaint. Please attach any photocopies of documents, including medical records if available, that are pertinent to your complaint. Do not send original documents. State in detail all facts which you believe justify your complaint.

You will receive confirmation of the receipt of your complaint by letter. If necessary, we may contact you for additional information and you will be notified when the process is completed.

Name of Complainant (first, middle, last):
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
Name of Patient (First, Middle, Last): If not complainant above
Date of Birth:
Address:
Phone:
City:
State:
Zip Code:
Complaint Against:
* If your complaint involves more than one provider, please fill out separate complaint form for each provider.

1. What are the dates that the provider in question cared for you/patient?
2. Have you contacted the provider directly about your complaint?
3. Did any other providers treat you/patient after the alleged incident?
4. Have you/patient been treated at any hospitals or urgent care facilities related to this complaint?
5. Have you filed this complaint elsewhere?
6. What action was or is being taken?
7. Please describe your complaint in detail (attach extra sheets if necessary)

File NameSize

PLEASE NOTE: We may forward this complaint to the practitioner in question. Your signed complaint may be 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 SOUTH DAKOTA BOARD OF MEDICAL AND OSTEOPATHIC EXAMINERS.

SIGNATURE OF COMPLAINANT
Date: