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?

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

Narrative:

Is this an issue pertaining to obtaining medical records? No

Have you submitted a medical record release form to your provider? 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 or hospital where this event occurred:

Address:

Have you contacted the licensee about your concerns? No

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

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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