Florida state form:
http://www.doh.state.fl.us/mqa/enforcement/frm_psyUCF.pdf
DIVISION OF MEDICAL QUALITY ASSURANCE Enforcement Program Health care practitioners are regulated by the Department of Health nd the action which may be taken is administrative in nature, e.g., reprimand, fine, restriction of practice, remedial education, administrative cost, probation, license suspension or license
revocation. The Department cannot represent you in civil matters to recover fees paid or seek remedies for injuries. You may wish to consult a private attorney regarding these matters.
The Department of Health investigates complaints and reports involving health care practitioners and enforces appropriate Florida Statutes.
FIND THE WHOLE FORM HERE:
http://www.doh.state.fl.us/mqa/enforcement/frm_psyUCF.pdf
HOW TO FILE A COMPLAINT/REPORT AGAINST A HEALTH CARE PRACTITIONER: · To file a complaint/report, you must do so in a signed, written report. For your convenience you may use this form providing dates and details about your complaint.
· Use a separate complaint form for each practitioner you wish to file a complaint against.
· Be specific and include copies of pertinent medical records, correspondence, contracts, and any other documents that will help support your complaint.
· Medical records are needed to process your complaint. Since a health care practitioner cannot disclose his or her patient names or records with authorization, the Authorization for Release of Patient Information form included on page 3 must be completed and signed. Signatures must be witnessed or notarized.
· The Department will notify you in writing of the status of your complaint throughout the process. Please advise us of any address change.
· If the allegations contained in your complaint/report are determined to be possible violations of applicable laws and rules, your complaint will be opened for investigation.
· Please note that if your complaint is assigned for investigation, a copy of the complaint form will be provided to the health care practitioner pursuant to Florida law.
· The Department may investigate an anonymous complaint if the complaint is in writing and is legally sufficient, if the alleged violation of law or rules is substantial, and if the department has reason to believe, after preliminary inquiry, that the violations alleged in the complaint are true.
· If you are reporting Medicaid Fraud, you may be entitled to a reward through the Office of the Attorney General. For information and to report Medicaid Fraud, please contact the Attorney General’s Fraud Hotline by calling 1-866-966-7226 or online at http://ahca.myflorida.com and clicking the “Report Fraud” button.