Complaint form (pdf) - State of Idaho Board of Medicine - Idaho 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal information in Section I. Include your name, address, and contact numbers. Ensure all details are accurate for effective communication.
3. In Section II, identify the health care provider related to your complaint. Check the appropriate box for their designation (MD/DO, Physician Assistant, etc.) and provide their name and business address.
4. Detail the date(s) of the incident or care in the designated field. This helps establish a timeline for your complaint.
5. In Section III, provide a factual account of your concerns regarding the care received. Use additional sheets if necessary to ensure clarity and completeness.
6. Complete Section IV by indicating whether this provider is your primary health care provider and if you were referred to them.
7. Sign and date the authorization section to allow for the release of relevant medical information. Remember, a submitted form without a signature will not be accepted.

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