Complaint Form for the Durable Medical Equipment - NABP 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the required information about the facility. Include the name, street address, city, state, postal code, and phone number.
3. Next, provide your information as the complainant. While this is recommended, you can choose to remain anonymous. Fill in your name, address, email, and best contact time.
4. If applicable, enter details for the Medicare beneficiary or patient. You can check the box if their information is the same as yours.
5. Indicate the date of the incident and specify the DME item involved (e.g., blood glucose monitor).
6. In a brief narrative description, outline your complaint including relevant details such as dates and names of witnesses without sharing medical information.
7. State your desired resolution or outcome clearly.
8. Finally, indicate whether NABP or a regulatory agency may contact you for further clarification before submitting your form.

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