Office of Unlicensed and Complementary and Alternative Health Care 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:

Office of Unlicensed Complementary and Alternative Health Care Practice
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: (_____)__________________
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

Pursuant to Minnesota Statutes, sec. 146A.06, subd. 2, data about a client, complainant, and unsubstantiated data as part of an active investigation against a practitioner is private data. Pursuant to Minnesota Statutes, sec. 13.39, subd. 2, data collected by state agencies as part of an active investigation undertaken for the purposes of the commencement or defense of a pending civil legal action are classified as confidential. "Private data" is data which is not public and is accessible only to the subject of the data (Minnesota Statutes, sec. 13.02, subd. 12). "Confidential" data is data which is not public and is not accessible to the subject of the data or anyone (Minnesota Statutes, sec. 13.02, subd. 3).

The information you provide to MDH as part of this complaint will be investigated and used as part of the investigation of the practitioner's conduct. In some circumstances, the information you provide MDH will be disclosed to certain other persons or entities, including the Minnesota Attorney General's Office, the Office of Administrative Hearings, Department of Human Services, health-related licensing boards, law enforcement agencies, the Office of Ombudsman for Mental Health and Developmental Disabilities, federal agencies such as the Federal Department of Health and Human Services, and any subsequent reviewing court and any other government agency deemed necessary by the MDH;

As a consumer/client, you are not required to cooperate in an investigation by 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.

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?
_______________________________________________________

 

Information Specific to Practitioner and Involved Client

For the practitioner listed on the complaint form, please list any professional titles used by that practitioner:
_______________________________________________________

Please indicate the conditions or reasons for which the client/consumer involved in the incident sought services from the practitioner (check below any which apply):

_____ pain relief or treatment due to specific medical diagnosis (i.e., cancer, autoimmune conditions, arthritis, etc.
Please identify the medical diagnoses___________________________________
_____ back, shoulder, neck pain
_____ headaches (If yes, were these headaches migraines? _____Yes _____No
_____ insomnia
_____ digestive problems
_____ anxiety/stress
_____ depression
_____ addiction (nicotine, good, gambline)
_____ other (please identify) ___________________________________

Was the client/consumer also seeing a licensed physician for any of the conditions above?
_____Yes _____No

If yes, name the physician and reasons for seeing the physician.
_______________________________________________________

Was the physician involved in coordinating or communicating with this alternative health care practitioner?
_____Yes _____No

If yes, please describe: _______________________________________
_________________________________________________________
_________________________________________________________

Any questions please call 651-201-3721 or email Health.HOP@state.mn.us

Updated Wednesday, February 06, 2013 at 04:29PM