State of Colorado-Online Complaint Form

ONLINE COMPLAINT FORM

COMPLAINT FORM - DIVISION OF REGISTRATIONS

I wish to provide information about the practitioner named below. I understand that the Board does not represent private citizens seeking the return of their money or other personal remedies. The Board cannot give legal advice to individuals seeking to discover and enforce their private remedies. I understand that I may wish to consult a private lawyer to determine my legal rights and civil remedies, which are separate from a regulatory Board hearing. I am, however, filing this complaint to notify your office of the activities of this practitioner so that it may be determined if discipline against their license is warranted.

You may TYPE directly onto this form by tabbing from field to field and then print the document
or, print the document first and then LEGIBLY PRINT the required information.
Return to the address at the bottom of this page.

RESPONDENT INFORMATION (Complaint registered AGAINST):

Date of Complaint:

Respondent Name:

Telephone: License # (if known)

Address:

City/State/Zip:

1. Please provide a chronological statement of your complaint, including dates. If more space is needed, please attach additional paper.

2. Please attach a list names, address and telephone numbers of witnesses, including professionals. Attach copies of any police investigation including case number and a copy of the written report, if available.

3. Please attach copies of all documents relevant to your complaint, such as letters or other correspondence, contracts, witness statements, drawings and receipts.

4. Please sign the release at the end of this form. Failure to sign the release may result in the delay of the investigation of your complaint.

I attest that all statements made by me in relation to this complaint are true to the best of my knowledge and belief.

Signature: ______________________________________________________

COMPLAINANT INFORMATION (Person issuing a Complaint):

Complainant Name:

Address:

City/State/Zip:

Home/Contact Telephone:

Business/Facility Name (if applicable):

Address:

City/State/Zip:

Business Telephone:

RELEASE OF TREATMENT RECORDS

I hereby authorize you to release to the requesting Board of the Department of Regulatory Agencies all records and information, including X-rays, and models of any treatment and/or consultation of
Patient Name:
as may be requested by the Board in its investigation. A copy of my signature on this release shall be authorization and direction to release such records and information as is appropriate to the investigation of this complaint. These records are NOT public record and are requested solely for the purpose of the investigation of this complaint. Only individuals directly involved in this complaint process will have access to these records.

Date: Signature:

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