Healthcare Nursing Board Form

Healthcare Nursing Board Complaint & Authorization Form

This form is to report a complaint regarding nursing care or professional conduct and to authorize release of medical records necessary to the Nursing Board's review. The information provided will be used to evaluate allegations, determine whether further inquiry or enforcement action is warranted, and to obtain records from health care providers and facilities as authorized below.

Patient / Complainant Information

Patient Name:

Insurance Information (if applicable)

Incident Details

Date of Incident:    Time of Incident:

Medical & Treatment Information

Relief Requested / Scope of Complaint

Indicate requested actions (select all that apply):

Investigation to obtain facts regarding the incident
Disciplinary action if violations are substantiated
Monitoring or remedial education requirement
Other

Authorization to Obtain Records & HIPAA Acknowledgment

I hereby authorize any physician, hospital, clinic, nursing facility, health plan, provider, or other custodian of information to disclose and release to the Nursing Board and its authorized representatives all medical records, treatment records, nursing notes, incident reports, medication administration records, and other documents related to the incident and my care. This authorization includes records in electronic or paper form and any information necessary to evaluate the complaint. I understand that the Nursing Board may retain copies of records obtained under this authorization.

This authorization is valid until: . I understand I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on it.

HIPAA / Privacy Acknowledgment: I acknowledge that I have been informed of the purpose for which my protected health information will be used and disclosed as described above.

Legal Certification

I certify under penalty of perjury under applicable law that the information I have provided in this complaint is true and correct to the best of my knowledge. I understand that knowingly making a false statement may subject me to civil or criminal penalties. I consent to the release of the records identified above to the Nursing Board for purposes of investigation and administrative proceedings.

I further understand that this form does not create any private cause of action and that the Nursing Board will retain discretion to proceed or decline further action based on its investigation policies and applicable law.

Optional Additional Information

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