Georgia board of dentistry complaint form

Pdf File 465.89 KByte, 9 Pages

GEORGIA BOARD OF DENTISTRY COMPLAINT FORM

TYPE OR PRINT LEGIBLY AND MAIL TO THE ADDRESS LISTED BELOW

NOTE: The Georgia Board of Dentistry DOES NOT have authority over dental groups, practices, clinics or offices. Therefore, you must provide the full name of the individual dentist and/or hygienist- please do not list dental groups, practices, offices or clinics. Please keep a copy of this complaint information for your records. Once it is processed by the Board, it is confidential and cannot be provided back to you.

1. FULL NAME OF DENTIST/DENTAL HYGIENIST AGAINST WHOM YOU ARE FILING THE COMPLAINT:

(FIRST & LAST)

ADDRESS (STREET)

(CITY, STATE, ZIP CODE) TELEPHONE NUMBER ( ) LICENSE # (IF KNOWN)

2. COMPLAINANT'S NAME

DATE OF BIRTH

(FIRST, MIDDLE INITIAL, LAST)

(MM/DD/YYYY)

OTHER NAMES EVER USED

ADDRESS (STREET)

2 Peachtree St., NW, 36th Floor Atlanta, Georgia 30303 (404) 651-8000 (678) 717-6694 FAX gbd.

(CITY, STATE, ZIP CODE)

E-MAIL ADDRESS: _____________________________________________________________

PHONE NUMBERS

(

)

(BUSINESS)

MALE / FEMALE (Please circle one)

( _) (HOME)

(

)

(CELL)

3. PATIENT'S NAME (If different from complainant)

DATE OF BIRTH

______________________________________________________________________________

(FIRST, MIDDLE INITIAL, LAST)

(MM/DD/YYYY)

ADDRESS (STREET) (If different from complainant)

(CITY, STATE, ZIP CODE)

PHONE NUMBER (If different from complainant)

(

)

(BUSINESS)

( _) (HOME)

(

)

(CELL)

MALE / FEMALE (Please circle one)

4. NAME OF ADDITIONAL DENTIST/DENTAL HYGIENIST AGAINST WHOM YOU ARE FILING THE COMPLAINT:

NAME (FIRST & LAST)

ADDRESS (STREET)

(CITY, STATE, ZIP CODE) PHONE NUMBER ( )

2 Peachtree St., NW, 36th Floor Atlanta, Georgia 30303 (404) 651-8000 (678) 717-6694 FAX gbd.

LICENSE # (IF KNOWN) 5. ALLEGATION AND APPROXIMATE DATE(S) OF VIOLATION(S)

Please check box(es) below which describe the nature of your complaint. QUALITY OF CARE MISDIAGNOSIS OF CONDITION UNPROFESSIONAL CONDUCT UNSANITARY CONDITIONS PATIENT ABANDONMENT RECORDS RELEASE Note: If your complaint is based on failure to release patient records, you MUST

submit a written request to the dentist and give him/her a reasonable amount of time to respond to your request. Georgia law (O.C.G.A. ?31-33) allows the dentist to charge a reasonable fee for copying your records. You must include with this complaint a copy of a signed, certified mail return receipt, or any other document, showing that the provider received your request. INSURANCE FRAUD SUBSTANCE ABUSE UNLICENSED PRACTICE OTHER

APPROXIMATE DATE(S) OF VIOLATION:______________________________

6. PLEASE PROVIDE A CLEAR AND CONCISE DESCRIPTION OF THE INCIDENT OR NATURE OF YOUR COMPLAINT. Please include the date(s) and any other person(s) involved in this matter; attach COPIES of any relevant documents that you may have. (Attach copies only ? these materials will not be returned.)

2 Peachtree St., NW, 36th Floor Atlanta, Georgia 30303 (404) 651-8000 (678) 717-6694 FAX gbd.

7. HAVE YOU SEEN ANOTHER DENTIST(S) CONCERNING THIS ISSUE? IF SO, PLEASE PROVIDE THE FOLLOWING INFORMATION:

NAME OF PRIOR and/or SUBSEQUENT DENTIST/DENTAL HYGIENIST

(FIRST AND LAST)

ADDRESS (STREET)

(CITY, STATE, ZIP CODE)

PHONE NUMBER ( )

LICENSE # (IF KNOWN)

NAME OF PRIOR and/or SUBSEQUENT DENTIST/DENTAL HYGIENIST

(FIRST AND LAST)

ADDRESS (STREET)

(CITY, STATE, ZIP CODE) TELEPHONE NUMBER ( ) LICENSE # (IF KNOWN) NAME OF PRIOR and/or SUBSEQUENT DENTIST/DENTAL HYGIENIST

(FIRST AND LAST)

ADDRESS (STREET)

(CITY, STATE, ZIP CODE) TELEPHONE NUMBER ( ) LICENSE # (IF KNOWN)

AUTHORIZATION FOR RELEASE OF MEDICAL/DENTAL RECORDS

I hereby authorize any dentist, doctor or emergency facility/hospital who has treated me, or their office personnel, to release to the Georgia Board of Dentistry, or their representative, any and all information (including x-rays) that they may have, with respect to my condition, medical history, consultation, evaluation, treatment, diagnosis, or prognosis that may be inquired upon, and copies of all records regarding health history and treatment rendered to me. I further authorize the release of the above information with reference to any of children/wards listed below.

PLEASE PRINT except on signature line:

(Patient Name) (Patient Name) (Patient Name) (Patient Name) (Patient Name)

(Date of birth) (Date of birth) (Date of birth) (Date of birth) (Date of birth)

(Print Name of person providing the above referenced information)

(Signature)

(Date)

(Relationship to patient if other than self)

Download Pdf File