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Health Care Facility Complaint FormIllinois Department of

Health Care Facility Complaint FormIllinois Department of

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New York State Department of Health Office of Professional Medical Conduct Complaint Form Please print clearly and complete all sections of this form and mail to Office of Professional Medical Conduct Central Intake Unit Riverview Center 150 Broadway Suite 355 Albany, NY 12204-2719 This form must include your original signature. All reports of misconduct are kept confidential and are protected from disclosure ing to New York State Public Health Law, Sections 230(10)(a)(v) and 230(11)(a). Any person who reports or provides information to the Board for Professional Medical Conduct in good faith, and without malice, shall not be subject to an action for civil damages or other relief as the result of making the report ing to Section 230(11)(b). See Instructions on page four before completing this form. Instructions for Completing Complaint Form file a complaint about a physician, M.D. or D.O., Physician Assistant or Specialist Assistant licensed to practice medicine by the State of New Yor

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