Wednesday, February 22, 2017

File a Complaint Against a Psychiatrist  Below and this link PA   All States

Complaint Form Type:  

Please be aware that pursuant to Act 25 of 2009, 63 P.S. § 2205.1 if you submit a complaint anonymously the Department of State will not be able to share any information pertaining to the complaint with anyone, including you. 
A. Complainant InformationB. Complainant's Attorney, if any:
Your Name (Last/First/Middle):          
Name (Last/First/Middle):
Address:  Address:
City/ST/Zip:    City/ST/Zip:
County:  County:
Home Tel.: Work Tel.: 
Mobile Tel:
Home Tel.:Work Tel.:
Mobile Tel:
I wish to remain anonymous: 

C. Name and Address of Witness, if any.D. Name and Address of Second Witness, if any.
Name (Last/First/Middle):
Name (Last/First/Middle):
Address: Address:
City/ST/Zip:   City/ST/Zip:
County: County:
Home Tel.: Work Tel.:
Mobile Tel:
Home Tel.:Work Tel.:
Mobile Tel:
Is witness willing to appear at a hearing? Is witness willing to appear at a hearing?

E. Are you willing to appear at a hearing in Harrisburg if necessary?

Respondent Information

Please fill out the Business Establishment and Individual information below (secton F and G); it is required. If there is no information, then please enter 'NA' in each of the fields below (section F and G).

F. Business Establishment involved, if any.G. Individual involved, if any.
Name: Name (Last/First/Middle):
Address: Address: 
City/ST/Zip:   City/ST/Zip: 
County: County:
  Tel:    Tel: 
Proprietor:License Nbr:

H. For Notary Complaints only:

Expiration Date of Commission if known:Date of transaction for which this complaint is being filed:

I. Description of Complaint:

Please describe the facts of your complaint in detail below, in the order in which they happened.  List services provided by the licensee, registrant, certificate holder or commission holder.  Provide dates.  List fees paid for notary services, if applicable.     

Do you have any complaint-related contracts, bills, receipts, cancelled checks, correspondence, or any other documents you feel are related to your complaint?

If you answer yes to the above question, be sure to forward readable copies (not originals) of any complaint-related documents by mail to: Professional Compliance Office, Department of State, P.O. Box 69522, Harrisburg, PA 17106-9522. Please submit all supporting documents within ten days of submitting your on-line complaint so that we are able to process your complaint as quickly as possible. Due to the fact that your name will be used as your case identifier, when you mail your documents print or type your full name in the upper left-hand corner of every document that you submit. Retain the original documents and send only copies. (Additional documents cannot be attached to this form or sent electronically).

J. Resolution requested

How would you like this complaint to be resolved? 

K. Complainant's Verification and Electronic Signature

Please note that investigations by this office are confidential and privileged (See Section 5.1 of the Act of July 2, 1993 (Act 48), as amended, 63 P.S. § 2205.1). If this matter is closed without the initiation of formal disciplinary action, Act 48 prohibits this office from providing you with any additional information regarding the specific concerns which caused the file to be opened, the evidence gathered during our review and investigation, or the specific reasoning that led to this office's decision. Be sure to keep copies of all documents forwarded to the Commonwealth as confidentiality statutes may prevent us from returning these items to you. Additionally, Act 25 restricts access to this information while the file is under investigation.

I verify by typing my name below that the facts and statements set forth in this complaint are true and correct to the best of my knowledge, information and belief.  I understand that statements in this complaint are made subject to the criminal penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.

Typing your name on the line below and submission of this complaint form by clicking on the submit button below shows the complainant's intent to sign this complaint form electronically in accordance with the Electronic Transactions Act, Act 69 of 1999, 73 P.S. § 2260.101 et seq.

In addition, I authorize the Pennsylvania Department of State to use this information in any way that is necessary.
First Complainant's Name:     eMail: 
Second Complainant's Name:  eMail: 

Name of Person Completing Form if other than the complainant:
Name: eMail: 

Do you want a copy of this completed form to also be sent to all email addresses above?

No comments:

Post a Comment