MD. BCE - Complaint Form

COMPLAINT Form

PLEASE PRINT OR TYPE IN BLACK INK

The Board of Chiropractic Examiners investigates and acts upon complaints filed against licensed chiropractors if they involve violation of Maryland law concerning the chiropractic profession. If your complaint involves chiropractic treatment being rendered by someone other than a licensed chiropractor, this information is certainly of interest to the Board and should be forwarded to its attention as soon as possible.

In order to speed up the processing of your complaint, please include the correct names. addresses, telephone numbers (both home and business) of all persons named in the complaint. If certain information is not known by you, Please indicate same.

All complaints made to the Board are thoroughly considered and often referred for substantive investigation. If, after investigation, the Board brings charges against a chiropractor, advance notice must be given to the licensee to enable preparation of a defense. Therefore, in most cases, there is a considerable time lapse between the filing of the complaint and the hearing, if one is held. In all cases, you will be advised as to the outcome of your complaint. If, after investigation, the Board decides to proceed with a formal action, you may be called upon to testify as a witness.

If there is more than one person filing this complaint, please use a separate form for each person.

FULL NAME OF CHIROPRACTOR:
ADDRESS:

TELEPHONE NUMBER:
FULL NAME OF COMPLAINANT:
ADDRESS:

TELEPHONE NUMBERS:	HOME: _____________________		BUS.: ____________________
DATE OF BIRTH:	______ / _______ / ______	AGE: ________

Where you patient for this Chiropractor? ________Yes ________No

If so, from when to when _______________________________ to ____________________________________.

Have you discussed your concerns with this chiropractor? ________Yes ________No

What was the outcome ______________________________________________________________________

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Date(s) of occurrence(s) complained about _______________________________________________________

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Describe, in narrative form, with as much detail as possible, the exact nature of your complaint against this chiropractor. ______________________________________________________________________________
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For what condition were/are you being treated?
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Will you consent to the release to this Board or its designated investigating body, reports or records relating to you and to this occurrence from any health care provider or hospital, including the chiropractor complained of? ________Yes ________No
If yes, please authorize by signature	________________________________________________________
If no, why not?	________________________________________________________
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If the complaint is made by a person other than the patient, acting in an official or professional capacity, please furnish the following additional information. Also, please be sure to read, sign and date of the last page of this complaint form.
Your official title or designation	________________________________________________________
Did you personally investigate the matters set forth in this complaint? ________Yes ________No
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Do you have any reports or other written communications directed to you with respect to the matters complained of?
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If so, please attach to this complaint copies of these communications.
Is there any further information you wish to convey to the Board regarding this complaint?
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Date of Complaint	______________________________
Signature of Complainant	_________________________________________________
I HEREBY CERTIFY AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE MATTER AND FACTS SET FORTH IN THE FOREGOING COMPLAINT ARE TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.

Date	______________________________
Signature	_________________________________________________
DF 10/08

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