Professional Discipline Complaint Form
You may print this form and mail it to the nearest OPD office or fax it to: 212-951-6537. You may also call our Complaint Hotline 1-800-442-8106 or email conduct@mail.nysed.gov. See instructions below. You may also wish to see a description of New York's professional discipline system.
INFORMATION ABOUT YOU
Name ____________________________________________________________________
Address __________________________________________________________________
City ___________________ State _________ Zip __________ County ________________
Telephone: Day (______)__________________ Evening
(______)__________________
INFORMATION ON THE PERSON(S) YOU ARE COMPLAINING ABOUT
Name(s) __________________________________________________________________
Profession ______________________________ Telephone (______)__________________
Name of Hospital/Business/Store(if applicable) ___________________________________
Address _________________________________________________________________
City ___________________ State _________ Zip __________ County _______________
Describe your complaint here. Be specific. What happened? When? Where? Use black ink. Use additional sheets if necessary. Please read instructions carefully before describing your complaint.
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To the best of my knowledge, the information in this complaint is true and complete. Check here if you have included additional sheets/material ________.
Signature ___________________________________________ Date___________________ AUTHORIZATION
I, (print your name here)____________________________________, request and authorize the below-named licensed professional or practitioner and/or any other licensed professional or practitioner, and the below-named hospital or facility and/or any other hospital or facility, to disclose fully to the New York State Education Department and its authorized representatives all information and records relating to the diagnosis, treatment, prognosis made for and/or on my behalf, or service rendered for and/or on my behalf, by the said licensed professional, practitioner, hospital, or facility.
Name of practitioner(s) ______________________________________________________
Name of hospital(s) or other facilities ___________________________________________
Your signature _______________________________________ Date _________________
Signature of witness __________________________________ Date
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INSTRUCTIONS FOR COMPLETING COMPLAINT FORM
To complain about service or treatment by a professional licensed to practice by the State of New York, or about illegal practice of a profession by an unlicensed person, complete the COMPLAINT form above and send it to the Office of Professional Discipline. Please note that we do not have authority to investigate fees you believe are too high or to intervene in fee disputes. However, we can investigate complaints involving fraudulent billing.
Type or print clearly in black ink. Describe your complaint as completely as you can. If you do not have a daytime telephone number, it is helpful if you can provide a number where a message can be left for you during the day. If you have any papers which may support your complaint, such as bills or correspondence, please attach copies. Do not send originals. If you have physical evidence, such as incorrectly dispensed medications, it is important for you to retain that evidence in its original condition.
Be sure to sign and date your complaint. Send it to one of the regional offices of the Office of Professional Discipline. When your complaint is received, it will be assigned to an investigator who will contact you in writing or by telephone. You will have a opportunity to explain your complaint in more detail. If we do not have the authority to investigate your complaint we will refer it to the appropriate agency.
Also, complete the AUTHORIZATION form above by entering your name and the name of the practitioner and/or hospital in the appropriate spaces. The Authorization directs the professional, hospital, or other facility to release information about your treatment or the services rendered to you. Sign and date the Authorization, and have it signed and dated by a witness. A witness can be any person 18 year old or older. The Authorization does not have to be notarized. A completed Authorization helps us investigate your complaint in a timely manner. If you do not want to complete the Authorization, you may leave it blank. However, leaving the Authorization blank may delay the investigation.
IMPORTANT! Complaints against physicians
(general practitioners, internists,cardiologists, gynecologists,
pediatricians, urologists, psychiatrists, surgeons,
radiologists, oncologists, anesthesiologists, ophthalmologists,
orthopedists, and others) should be sent to New York State
Department of Health, Office of
Professional Medical Conduct, 433 River Street, Suite 303,
Troy, NY 12180-2299, 1-800-663-6114. All other
complaints should be sent to one of OPD's offices. Sending the complaint to the
wrong agency will delay the investigation.
