HID Complaint Form
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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: 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:___________________________________________ ________________________________________________________ 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 Their Telephone Numbers: Home: (_____)____________________ Business:(_____)___________________ Pager: (_____)_____________________ Cell: (_____)______________________ Fax: (_____)______________________ Their Birth Date: _____/_____/_____ Please check if you are: Information about the Practitioner who is the subject of the complaint: Practitioner Name: (first/middle/last)
_____________________________________ Practitioner's Address: _______________________________ _______________________________________________________ This address is: (check one) _____Home _____Business 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 WARNINGUnder 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:____________________________________________________ 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 2. Did the hearing aid dispenser also test your hearing? _____Yes / _____No 3. Was your hearing aid dispenser also an audiologist? 4. Did you purchase hearing aids in your home? 5. On what date did you sign purchase agreement? 6. On what date were your
hearing aids delivered? 7. Did you see a medical
doctor prior to purchasing the hearing aids? _____Yes / _____No 8. How many hearing aids did you buy? _____One / _____Two 9. What type of hearing aid did you buy? 10. What was the total purchase of your hearing aid(s)?
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