HID Complaint Form

To assist you with your complaint, the Minnesota Department of Health asks that you complete this form and submit it, with your written statement, via U.S. Mail to:

Hearing Instrument Dispensers
Health Occupations Program
Minnesota Department of Health
P.O. Box 64882
St. Paul, Minnesota 55164-0882

Based on the information you provide, an investigation will be conducted. Please type, or print clearly, using black ink.

Information about the person making the complaint:

Your Name: (first/middle/last)

______________________________________________

Check One:_____Mr. _____Mrs. _____Ms. _____Dr.

Your Address:___________________________________________

________________________________________________________

This address is: (check one) _____ Home _____ Business _____ School _____ Organization

Your Telephone Numbers:

Home: (_____)____________________

Business: (_____)_________________

Pager: (_____)___________________

Cell: (_____)____________________

Fax: (_____)____________________

Your Birth Date: _____/_____/_____

Is this complaint on your own behalf? Yes / No (Circle one)

If you answered "no" to the above question, please provide the following information concerning the consumer for whom you are filing this complaint:

Information about the Consumer:

Consumer Name: (first/middle/last) _________________________________________

Check One:_____Mr. _____Mrs. _____Ms. _____Dr.

Their Address:_________________________________________

_______________________________________________________

This address is: (check one) _____Home _____Business

_____School _____Organization _____Residential Facility

Their Telephone Numbers:

Home: (_____)____________________

Business:(_____)___________________

Pager: (_____)_____________________

Cell: (_____)______________________

Fax: (_____)______________________

Their Birth Date: _____/_____/_____

Please check if you are:
_____Client/Consumer
_____Another Professional Reporting
_____Agency
_____Relative/Friend
_____Practitioner Self Reporting
_____Anonymous
_____Practitioner's Supervisor
_____Other

Information about the Practitioner who is the subject of the complaint:

Practitioner Name: (first/middle/last) _____________________________________

Check One: _____ Mr. _____ Mrs. _____ Ms. _____ Dr.

Practitioner's Address: _______________________________

_______________________________________________________

This address is: (check one) _____Home _____Business

_____School _____Organization

Practitioner's Telephone Numbers:

Home: (_____)____________________

Business:(_____)____________________

Pager: (_____)____________________

Cell: (_____)____________________

Fax: (_____)____________________

Practitioner's Birth Date: _____/_____/_____

Practitioner Gender: _____Male _____Female

Name of Practitioner's Organization or Business:

_______________________________________________________

Address of Practitioner's Organization or Business:

_______________________________________________________

Narrative description of your complaint: On separate sheets, please describe what occurred, where and when the incident transpired and who was involved. Include in your narrative your relationship to the practitioner, where the practitioner was employed at the time of the incident, and any previous or subsequent encounters you may have had with the practitioner. If possible, please include the identities and phone numbers of anyone who may have either witnessed the incident or have additional information regarding either the incident or the practitioner. Please include copies of any supporting documents you may have. Please sign and date each narrative page. Your rights are described under the Tennessen Warning included with this form.

What would you like to see happen to resolve this complaint?

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

The information I have given is true and accurate to the best of my knowledge and may be used as stated in this form.

Signature: _____________________________________________

Date: __________________________________________________

 

TENNESSEN WARNING

Under the Minnesota Government Data Practices Act, information given to the Minnesota Department of Health (MDH) as part of an active investigation of a complaint against a practitioner is confidential. Such information is for the use of the MDH in the evaluation of the complaint, and if necessary, bringing legal action against the practitioner. In some circumstances, investigative information received from you about a practitioner may be disclosed to certain other persons or entities, including the Attorney General's Office, the Office of Administrative Hearings, members of any advisory council, any subsequent reviewing court and any other government agency deemed necessary by the MDH.

As a consumer, you are not required to cooperate with the MDH, but not cooperating could hamper our ability to investigate the matter. Practitioners regulated by MDH are required by statute to cooperate with an investigation by the MDH. A practitioner refusing to cooperate may result in the MDH taking disciplinary action against the practitioner.

After an investigation is closed, the investigative data is classified as private data pursuant to Minnesota Statute 13.41. Orders for hearing and specification of a final disciplinary action are public data pursuant to Minnesota Statute 13.41.

 

Client Records Waiver Authorization - (please complete, sign and date)

TO:____________________________________________________
(Client's physician, clinic, or applicable provider)

Having been informed of my rights under the Minnesota Government Data Practices Act, I authorize the physician, clinic or applicable provider named above to furnish a copy of my records in their possession, to allow those records to be inspected and/or copied by the MDH, and any other appropriate state or government agencies. I further authorize the physician, clinic, or applicable provider named above to testify without limitation as to any and all of their findings and/or treatment referred to in said records. I release the MDH, its agent(s), and the agent(s) of the Attorney General's Office representing the MDH from liability for so releasing said records or said testifying, and I waive my privileges afforded me by the law relating to the disclosure of introduction into evidence of health information.

This consent is subject to express revocation at any time except to the extent that action has been taken in reliance on this consent. Unless express revocation is made, this consent is revoked upon conclusion of the MDH's investigation. A photocopy of this release shall be as valid as the original. I also agree to permit and hereby authorize the MDH to use my name and/or records in any legal proceeding arising out of this matter.

NAME: (please print) __________________________________

DATE: ___________________________

SIGNATURE authorizing release of information:

_______________________________________________________

If not signed by the client involved in the matter, what is your relationship to the client?

_______________________________________________________

 

HID SPECIAL INFORMATION:

1. Hearing aid buyer's date of birth
_____/______/____
Month / Day / Year

2. Did the hearing aid dispenser also test your hearing? _____Yes / _____No

If no, who tested your hearing and when? _________________________________________

3. Was your hearing aid dispenser also an audiologist?

_____Yes / _____ No / _____ Don't know

4. Did you purchase hearing aids in your home?

_____Yes / _____No

5. On what date did you sign purchase agreement?
_____ / ____ /_____
Month / Day / Year

6. On what date were your hearing aids delivered?
_____ / ____ /_____
Month / Day / Year

7. Did you see a medical doctor prior to purchasing the hearing aids? _____Yes / _____No

If yes, when did you see the doctor and did the doctor evaluate your hearing or ears?

________________________________________________________

8. How many hearing aids did you buy? _____One / _____Two

9. What type of hearing aid did you buy?

_____ Body Type / _____BTE (Behind the Ear) / _____ ITE (In the Ear)

_____ CIC (Completely in the canal)

10. What was the total purchase of your hearing aid(s)?

_____ $0.00 - $500.00
_____ $501.00 - $800.00
_____ $801.00 - $1000.00
_____ $1001.00 - $2000.00
_____ $2001.00 - $3000.00
_____ Over $3000.00

Updated Wednesday, October 19, 2011 at 12:53PM