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Get and Sign Ohio Complaint Form
Filing your complaint and retain this page for future reference. Your healthcare or payment for care will not be affected by whether you sign this authorization. A photocopy or facsimile of this authorization will have the same authority as the original. Revocation of Release of Information I hereby withdraw my consent for this release of information. Gov Statement of Complaint Directions This form is for use by any person interested in submitting a complaint against a licensee or registrant of...
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