Complaint Gateway | North Carolina Medical Board

Complaint Report

Incident Information

It is recommended that you compose your complaint statement as a document and save it to your computer. You may cut and paste the text of your statement into the space below, or send your statement as an attachment. This will provide you with a written record of your complaint and prevent the loss of your statement in the event of technical difficulties with this form.

How did you hear about the NC Medical Board?

Other:

The Board does not regulate billing/fee/insurance issues.

Narrative: Characters: /

Is this an issue pertaining to obtaining medical records?

Have you submitted a medical record release form to your provider?

Is this an issue pertaining to obtaining a signature on a death certificate?

Is this complaint based on sexual misconduct by a medical provider? (Know the Signs of Sexual Misconduct)

If you need more space to explain, please upload a document on the Uploads page to follow.

When did this event occur? Please list specific dates of service. Characters: /

Full name of practice or hospital where this event occurred:

Address 1:

Address 2:

Zip, City, State:

Have you contacted the licensee about your concerns?

What was the licensee's response? Characters: /

What would you consider to be a fair resolution to your complaint? (The Board cannot assist with compensation) Characters: /

Please report the agency name and contact person Characters: /

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