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:

PLEASE NOTE: The Board cannot assist with billing issues (excluding fraud), insurance issues, financial compensation, or filing a lawsuit. Please visit the Board’s website and view our complaint video tutorial for a list of agencies that may be able to assist you with these topics.

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, hospital, clinic, or facility 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: /

ADDITIONAL HEALTH CARE PROVIDER INFORMATION
If additional health care providers, facilities, clinics, or hospitals were involved in your care (or the care of the patient) related to the complaint, you MUST provide the names, addresses, and date(s) of service of EACH location and/or provider where you (or the patient) received care in the space below: If you do not have sufficient space, then you may attach a separate typed document.

Add Additional Healthcare Provider

Name of health care provider...	Location/Address	Phone	Care Provided	Dates of Treatment
No information entered.

Please report the agency name and contact person Characters: /

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