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:
Health Occupations Program
Office of Unlicensed Complementary and Alternative Health Care Practice
Minnesota Department of Health
P.O. Box 64882
St. Paul, Minnesota 55164-0882
Instructions: Please type or print and handwrite clearly, using blue ink. Sign and mail in your completed forms.
Based on the information you provide, an investigation will be conducted.
Narrative description of your complaint: 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. If you need more space, you may include additional pages. Please sign and date each statement of complaint page. Your rights are described under the Tennessen Warning included with this form.
The document on this page is provided in PDF format. To fill in PDF files electronically you will need to download a free copy of Adobe Acrobat Reader or Adobe Acrobat Reader for Visually Impaired Readers. Adobe provides a free download for these applications at their website.
Any questions please call 651-201-3729 or email Health.HOP@state.mn.us