Nys professional discipline complaint form 2012-2026

1. Click ‘Get Form’ to open the NYS Professional Discipline Complaint Form 2012 in the editor.
2. Begin by filling out the 'Information About You' section. Enter your name, address, city, state, zip code, county, and daytime and evening telephone numbers. Ensure all details are accurate for effective communication.
3. In the 'Information on the Person(s) You Are Complaining About' section, provide the name(s), profession, and contact information of the individual or entity you are filing a complaint against.
4. Describe your complaint in detail. Be specific about what happened, when it occurred, and where it took place. Use black ink if you are printing or type directly into the fields provided.
5. Sign and date your complaint at the bottom of the form. If you have additional sheets or supporting documents, check the box indicating their inclusion.
6. Complete the Authorization section by entering your name and that of the practitioner or facility involved. Sign this section as well as having a witness sign it.
7. Once completed, submit your form to the appropriate regional office listed on the document to ensure timely processing of your complaint.

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