Complaint Gateway | North Carolina Medical Board

Complaint Report

Verification

Please take a moment to verify all information below. If you see any errors, use the previous button to correct information. Once all information is correct, use the next button to proceed.

Your Information

Name:

Address:

Daytime Phone Number:

Other Phone Number:

Your Email Address:

Patient Information

Name:

Date of Birth:

Relationship to Patient:

Practitioner/Respondent Information

Name:

License #

Primary Practice:

Specialty:

Licensee's Phone Number:

Incident Information

How did you hear about the NC Medical Board?

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:

Is this an issue pertaining to obtaining medical records? No

Is this an issue pertaining to obtaining a signature on a death certificate? No

Is this complaint based on sexual misconduct by a medical provider? No

When did this event occur?

Full name of practice, hospital, clinic, or facility where this event occurred:

Address:

Have you contacted the licensee about your concerns? No

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.

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

By checking this box, I swear or affirm that all information contained on and with this form is true and correct to the best of my knowledge.

I Agree

Your Information

Patient Information

Practitioner/Respondent Information

Incident Information

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