Kansas State Board of Healing Arts: Complaint Form

KANSAS STATE BOARD OF HEALING ARTS
235 S. Topeka Boulevard – Topeka, KS 66603-3068

ATTN: Complaint Coordinator
Phone: (785) 296-7413 – Fax: (785) 368-7103
COMPLAINT FORM
INSTRUCTIONS: (Please Type or Print)
Please furnish all identifying information for the complainant, the patient and all practitioners and
facilities involved in the complaint. When providing your address, the address of the patient or the
practitioner, list the street address, not a post office box. Please complete all pages of this form.
Additional pages may be added if necessary.
PERSON MAKING COMPLAINT: (Please notify this agency if the following information changes.)
NAME:__________________________________________________________________________
First Middle Last Other Names Used
ADDRESS:______________________________________________________________________
Street City State Zip Code
HOME PHONE:( )_________________________ WORK PHONE:( )______________________
May we contact you at your place of employment? YES _____ NO _____ (Agency working hours are 8:00 a.m.
to 4:30 p.m.) Best time to contact you would be? __________a.m./p.m. to __________ a.m./p.m.
PATIENT INFORMATION:
NAME:__________________________________________________________________________
First Middle Last Other Names Used
ADDRESS:_______________________________________________________________________
Street City State Zip Code
DATE OF BIRTH:__________________________
SSN:_______________________________________
HOME PHONE:( )_________________________ WORK PHONE:( )______________________
PRACTITIONER(S) AGAINST WHOM ALLEGATION IS MADE: (Please identify practitioner with

the appropriate title: (M.D., D.O., D.C., D.P.M., P.A., P.T., P.T.A., O.T., O.T.A., R.T., A.T., N.D., C.L.)
NAME:__________________________________ NAME:
ADDRESS:_______________________________ ADDRESS:
PHONE:( )______________________________ PHONE:( )____________________________

FACILITIES INVOLVED IN THE INCIDENT: (Hospitals, Nursing Homes, Clinics, Etc.)
FACILITY:______________________________ FACILITY:______________________________
ADDRESS:_____________________________ ADDRESS:______________________________
______________________________________ _______________________________________
PHONE:( )____________________________ PHONE:( )_____________________________
FACILITY:______________________________ FACILITY:______________________________
ADDRESS:_____________________________ ADDRESS:______________________________
______________________________________ _______________________________________
PHONE:( )____________________________ PHONE:( )_____________________________
WITNESS(ES) TO THE INCIDENT: (If known)
NAME:________________________________ NAME:__________________________________
ADDRESS:_____________________________ ADDRESS:______________________________
______________________________________ ________________________________________
PHONE:( )____________________________ PHONE:( )______________________________

Home and Work Home and Work
NAME:________________________________ NAME:__________________________________
ADDRESS:_____________________________ ADDRESS:_______________________________
______________________________________ ________________________________________
PHONE:( )____________________________ PHONE:( )______________________________

Home and Work Home and Work
PLEASE LIST A FRIEND OR RELATIVE WHO WILL KNOW YOUR MOST CURRENT ADDRESS
AND PHONE NUMBER.
NAME:_______________________________________
ADDRESS:____________________________________
PHONE:( )___________________________________
Home and Work
NARRATIVE
Please describe in detail all allegations against the practitioner(s). Describe each incident with specific
dates and list any witnesses. Attach copies of any documents you have concerning the allegations.
Use additional sheets if necessary.
DATE OF INCIDENT:______________________ PATIENT’S NAME:_________________________

YOUR RELATIONSHIP TO PATIENT, IF OTHER THAN YOURSELF: _________________________
I acknowledge that the Kansas Board of Healing Arts may provide a copy of this form to the person
against whom the allegations are made. I agree to testify in any hearings which may arise as a result
of these allegations. The statements I have made are true and correct to the best of my knowledge and
belief.
DATE:_____________________ SIGNED:______________________________________________
GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION
I ________________________________________________hereby authorize the use or disclosure of my health

information as described in this authorization.
1. Specific person/organization authorized to provide the information:

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________.
2. The Kansas Board of Healing Arts, (“the Board”) its representatives, agents or employees are specifically
authorized to receive and use my health information. Please send information to:
Kansas Board of Healing Arts
ATTN:__________________
235 S. Topeka Blvd.
Topeka, Kansas 66603-3068
3. I specifically authorize the release of all of my health information in your possession or control including
medical records of every kind, billing information, films, monitor strips, and any record requested by the Board.
4. The purpose of this request is to permit the Kansas Board of Healing Arts access to all of my health information
necessary in furtherance of health oversight activities.
5. I understand I have the right to revoke this authorization at any time by notifying the Kansas Board of Healing
Arts in writing at 235 S. Topeka Blvd., Topeka Kansas 66603-3068. I understand that the revocation is only effective after
it is received by the Board. I understand that any use or disclosure made prior to the revocation under this authorization
will not be affected by a revocation.
6. I understand that after this information is disclosed, federal law might not protect it and the recipient might re-
disclose it to other health oversight agencies and law enforcement entities as permitted by state law.
7. I understand that if I do not sign this authorization, the Kansas Board of Healing Arts may not be able to fully
investigate my complaint. I also understand that in furtherance of health oversight activities, the Kansas Board of Healing
Arts possesses subpoena power that permits them to command the disclosure of my health information from certain
individuals and entities without my permission. This authorization is intended to permit individuals and entities not subject
to the Board’s subpoena power to provide copies of my health information to the Board.
8. I understand that I am entitled to receive a copy of this authorization.
9. I understand that this authorization will expire upon completion of the Kansas Board of Healing Art’s
investigation into the matter(s) about which I am complaining, or upon the completion of any legal proceedings that might
arise out of my complaint, whichever event is latest.
_____________________________________ _____________________
Signature of Patient Date
OR:
_____________________________________ _____________________
Signature of Personal Representative Date
(signature warrants he/she has authority to sign as Personal Representative)
_____________________________________
Patient’s Date of Birth
CF-11/04

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KANSAS STATE BOARD OF HEALING ARTS

235 S. Topeka Boulevard – Topeka, KS 66603-3068

INSTRUCTIONS: (Please Type or Print)

HOME PHONE:( )___ WORK PHONE:( )

HOME PHONE:( )___ WORK PHONE:( )

PRACTITIONER(S) AGAINST WHOM ALLEGATION IS MADE: (Please identify practitioner with

PHONE:( )__ PHONE:( )

PHONE:( ) PHONE:( )_

PHONE:( ) PHONE:( )_

WITNESS(ES) TO THE INCIDENT: (If known)

PHONE:( ) PHONE:( )__

PHONE:( ) PHONE:( )__

DATE OF INCIDENT: PATIENT’S NAME:___

I ________________________________________________hereby authorize the use or disclosure of my health

1. Specific person/organization authorized to provide the information:

8. I understand that I am entitled to receive a copy of this authorization.

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