Transcription of Consumer Complaint Form
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Consumer Complaint Form
BUSINESS, Consumer SERVICES, AND HOUSING AGENCY Department of Consumer Affairs EDMUND G. BROWN JR., Governor MEDICAL BOARD OF CALIFORNIA Central Complaint Unit 07I-61 (Revised 9/2017) 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2528 FAX: (916) 263-2435 Consumer Complaint form Instructions for Filing Your Complaint Fill in the full name, address, telephone number, and license number (if known) of the person your Complaint is against. Also write this information in the corresponding section of the Authorization for Release of Medical Information form on the reverse side of the Complaint Details form .
07I-61 (Revised 9/2017) COMPLAINT REGISTERED AGAINST I wish to file a complaint against the individual named below. I understand that the Medical Board does not
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