102dlsc pdf 2025

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The document is a complaint form and authorization for release of information from the Wisconsin Department of Safety and Professional Services. It provides instructions for filing a complaint against health care professionals, detailing required information such as personal details of the complainant and patient, incident specifics, and necessary authorizations for accessing health care records. The document emphasizes the importance of providing comprehensive information to facilitate investigations.

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Click ‘Get Form’ to open the 102dlsc PDF in the editor.
Begin by filling in your personal information at the top of the form. Include your name, address, phone number, and email address.
If applicable, provide the patient's name and date of birth. This is crucial for identifying the individual related to the complaint.
In the section regarding the complaint details, clearly describe when and where the incident occurred. Be as specific as possible to ensure clarity.
If you have attempted to resolve this matter previously, include those details in the designated area.
Complete any additional sections that pertain to other involved parties or entities. Ensure all fields are filled accurately.
Finally, sign and date the form at the bottom before submitting it through our platform for processing.

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Versions	Form popularity	Fillable & printable
2015	4.9 Satisfied (513 Votes)
2014	4 Satisfied (39 Votes)

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