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.
City:
State:
Zip Code:
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?
6. What action was or is being taken?
7. Please describe your complaint in detail (attach extra sheets if necessary)
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.