STATE OF MICHIGAN
GRETCHEN WHITMER
GOVERNOR
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
LANSING
ORLENE HAWKS
DIRECTOR
BU
REAU OF PROFESSIONAL LICENSING
611 W. OTTAWA • P.O. BOX 30670 • LANSING, MICHIGAN 48909
www.michigan.gov/bpl • 517-241-0199
LARA is an equal opportunity employer/program
Instructions for Filing a Complaint
Please fill out the following attached forms:
NOTE: All nursing complaints file on-line at: www.Michigan.gov/MiPLUS select file a nursing
complaint under the quick links.
• Bureau of Professional Licensing Complaint Form
• Treatment Data Form (If Applicable)
• Authorization for Release of Privileged/Client Information Form (If Applicable)
To be signed by patient, his or her representative, or guardian if the patient is a
minor
Samples of completed forms are included to assist you
Include the patient’s date of birth and last 4 digits of their social security number, if
applicable.
Include all relevant documents that support your allegation.
Please ensure all submitted documents are legible.
If you are signing this release on behalf of a patient, who is not a minor child, you must
provide us with a Letter of Authority, issued by the probate court, which empowers you
to act on behalf of the patient.
Upon submission of your information a determination will be made if an investigation
can be initiated. You may also be contacted with a request for additional information or
documentation.
If you have any questions in completing the enclosed forms, contact our office at (517) 241-0205.
You may submit your complaint by one of the following methods:
Mail:
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
ATTN: Complaint Intake Section E-Mail: BPL-Complaints@michigan.gov
611 W. Ottawa Street, PO Box 30670
Lansing, MI 48909-8170 FAX: (517) 241-2389
Form Date: 2-08-2019
Inv
estigations & Inspections Division
Office Use Only
Information About You
Complaint Being Filed Against
Please be advised this agency DOES NOT assist citizens seeking reimbursement or resolution of billing or fee disputes or
investigate anonymous complaints. In addition, this agency DOES NOT handle complaints against health care facilities.
INSTRUCTIONS: Print legibly or type information. Complete all sections of this form. Sign at the bottom. Return the form to the address
above. Please complete a separate form for each practitioner you are filing a complaint against.
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age,
national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the
Americans with Disabilities Act, you may make your needs known to this agency.
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909-8170
(517) 241-0205
BPL/IID-200 (12/18)
File #:
Your Name
Practitioner’s First and Last Name
Street Address
Street Address
City
City
State Zip Code
County
State Zip Code
Patient’s Name
Practitioner’s Telephone Number
Patient’s Date of Birth (MM/DD/YYYY)
Treatment/Incident Date
Patient’s Last 4 Digits of Their Social Security Number
Your Telephone Numbers Including Area Code
Cell:
Home: Work:
Check the profession for which you are lodging a complaint about:
Sanitarian
Social Worker
Speech/Language Pathologist
Veterinary Medicine
Acupuncture
Athletic Trainer
Audiologist
Behavioral Analyst
Chiropractor
Counselor
Dentistry / Hygienists /Dental Asst.
Marriage & Family Therapist
Massage Therapist
Nursing Home Administrator
Occupational Therapist
Optometry
Pharmacist / Pharmacy Technician
Physician (M.D. or D.O.)
Physician’s Assistant
Physical Therapist
Podiatrist
Psychologist
Respiratory Therapist
Are there civil actions pending?
Yes No
Is there a police report?
Yes No
May we release your name and this
information to the practitioner?
Yes No
Will you testify at an Administrative
Hearing if necessary?
Yes No
Please provide details of your specific concerns related to the treatment rendered. Attach additional sheets if necessary.
Your Signature
Would you like to authorize a person other than yourself to
communicate with the Department regarding your complaint?
Yes No
Name:
Address:
Telephone Number:
Relationship to You:
I authorize the Department to release my name, and all relevant information pertaining to this allegation, to other law enforcement agencies. I understand that I am under no
obligation, whatsoever, to do so.
Date
Office Use Only
BPL/IID-201 (12/18)
TREATMENT DATA FORM
NAME OF PATIENT: ___SMITH_______________MARY________________P._________
LAST FIRST M.I.
Date of Birth: __01/01/1955 _ Last 4 digits of Social Security Number: ___6780___
NAME, ADDR
ESS AND PHONE NUMBER OF DOCTOR(S) AND/OR HOSPITAL(S) PROVIDING
TREATMENT FOR THE SAME CONDITION STATED IN COMPLAINT:
FULL NAME: ___JOHN DOE, M.D._________ Dates of Treatment:
ADDRESS: ___
123 MAIN STREET _____ Beginning: ____MAY 2017 ______
CITY/ST
ATE/ZIP: __
LANSING, MI 48910__ Ending:
____SEPTEMBER 2018
TELEPH
ONE: ____
(517) 361-5858_________
FULL NAME: __GOOD SAMARITAN HOSP. Dates of Treatment:
ADDRESS: __789 FIRST STREET_______ Beginning:
CITY/ST
ATE/ZIP: _
LANSING, MI 48912____ Ending:
___AUGUST 24, 2018
___AUGUST 31, 2018
TELEPH
ONE: _____
(517) 361-5676_______
FULL NAME
: ___________________________ Dates of Treatment:
ADDRESS: _
__________________________ Beginning: _____________________
CITY/STATE/ZIP: _______________________ Ending: _____________________
TELEPH
ONE: ___________________________
FULL NAME: ___________________________ Dates of Treatment:
ADDRESS: _
__________________________ Beginning: _____________________
CITY/ST
ATE/ZIP: _______________________ Ending: _____________________
TELEPH
ONE: ___________________________
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age,
national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the
Americans with Disabilities Act, you may make your needs known to this agency.
Completion: Voluntary Penalty: None Authority: P.A. 368 of 1978, as amended
FILE NUMBER:
~ SAMPLE ~
State of Michigan
Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
Office Use Only
BPL/IID-201 (12/18)
TREATMENT DATA FORM
NAME
OF PATIENT: _________________________________________________________
LAST FIRST M.I.
Date of Birth: _________________ Last 4 digits of Social Security Number: ___________
NAME,
ADDRESS AND PHONE NUMBER OF DOCTOR(S) AND/OR HOSPITAL(S) PROVIDING
TREATMENT FOR THE SAME CONDITION STATED IN COMPLAINT:
FUL
L NAME: _______________________________ Dates of Treatment:
ADD
RESS: ___________________________ Beginning: _____________________
CI
TY/STATE/ZIP: _______________________ Ending: _____________________
TELEPHONE: ___________________________
FULL NAME: ___________________________ Dates of Treatment:
ADD
RESS: ___________________________ Beginning: _____________________
CI
TY/STATE/ZIP: _______________________ Ending: _____________________
TE
LEPHONE: ___________________________
FULL NAME: ___________________________ Dates of Treatment:
ADD
RESS: ___________________________ Beginning: _____________________
CI
TY/STATE/ZIP: _______________________ Ending: _____________________
TELEPHONE: ___________________________
FULL NAME: ___________________________ Dates of Treatment:
ADDRESS: ___________________________ Beginning: _____________________
CI
TY/STATE/ZIP: _______________________ Ending: _____________________
TE
LEPHONE: ___________________________
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age,
national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the
Americans with Disabilities Act, you may make your needs known to this agency.
Completion: Voluntary Penalty: None Authority: P.A. 368 of 1978, as amended
State of Michigan
Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
FILE NUMBER:
Office Use Only
AUTHORIZATION FOR RELEASE OF PRIVILEGED/CLIENT INFORMATION
I, _______MARY SMITH________________, hereby authorize ________JOHN DOE, M.D.___________________
(Patient/Client/Representative’s Name) (Doctor/hospital/program or other custodian of record name)
1234 Main Street, Lansing MI 48910
(Address of doctor/hospital/program or other custodian of records)
To rele
ase/exchange information contained in the records of:
MARY SMITH
01/01/1955
6789
Patient’s Name Date of Birth Last 4 digits of Social Security Number
1. Name of person(s) or organizations(s) to whom disclosure is to be made:
Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Professional Licensing, Investigations &
Inspections Division, 611 W. Ottawa, P.O. Box 30670, Lansing, Michigan 48909-8170 or the Department of Attorney
General.
2. Spec
ific type of information to be disclosed:
Any and all MEDICAL information that may have been obtained or made including, but not limited to, all medical
records, alcohol, drug abuse and mental health records, billing records, pathology, radiology and laboratory reports,
consents, authorizations or waiver forms, and any other documentation. I understand that this information may
include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV
infection, Acquired Immune Deficiency Syndrome or AIDS related Complex) and any other communicable diseases. It
may also include information about behavioral or mental health services, and referral or treatment for alcohol and
drug abuse (as permitted by 42 CFR, Part 2).
3. The pur
pose and need for such disclosure:
I understand that the Department of Licensing and Regulatory Affairs, Bureau of Professional Licensing and/or the
Department of Attorney General may use any information and records so released in connection with the
administration and enforcement of the laws of this State and of the United States.
4. I un
derstand that if I give LARA permission I have the right to change my mind and revoke it. This must be in
writing to: Privacy Office, Michigan Department of Licensing and Regulatory Affairs, Investigations and Inspections
Division, 611 W. Ottawa St., Lansing, MI 48933. I also understand that LARA cannot take back any uses or
disclosures already made with my permission. Unless otherwise revoked or if I fail to specify an expiration date,
event or condition, this authorization will expire ONE (1) year from the signature date.
5. By signing this Authorization, I understand that any disclosure of information carries with it the potential for an
unauthorized re-disclosure and the information may not be protected by federal privacy rules. I further understand I
may request a copy of this signed authorization.
A copy
of this authorization shall serve in the stead of the original.
______________Mary Smith____________________________ _____1/14/2018___________________
Patient/Client or Representative’s Signature Date Signed
(If signed by a Legal Representative, relationship to the Patient/Client.
A letter of authority may be required)
____________Tim Smith__________________________________ _____1/14/2018____________________
Witness’ Signature Date Witnessed
______1/14/2018___________________
Date Prepared
This authorization is acceptable to the Michigan Department of Licensing and Regulatory Affairs as compliant with HIPAA privacy regulations, 45 CFR, Parts 160 & 164, as modified
December 11, 2003. If you need assistance with reading, writing, hearing, etc., under the American’s with Disability Act, you may make your needs known to this Agency.
Completion: Voluntary Penalty: None Authority: P.A. 368 of 1978, as amended
State of Michigan
Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909-8170
BPL/IID-202 (12/18)
FILE NUMBER:
~ SAMPLE~
Office Use Only
AUTHORIZATION FOR RELEASE OF PRIVILEGED/CLIENT INFORMATION
I, __
_________________________________, hereby authorize __________________________________________
(Patient/Client/Representative’s Name) (Doctor/hospital/program or other custodian of record name)
(Address of doctor/hospital/program or other custodian of records)
To re
lease/exchange information contained in the records of:
Patient’s Name Date of Birth Last 4 digits of Social Security Number
1. Name of person(s) or organizations(s) to whom disclosure is to be made:
Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Professional Licensing, Investigations &
Inspections Division, 611 W. Ottawa St., Lansing, Michigan 48933 or the Department of Attorney General.
2. Spe
cific type of information to be disclosed:
Any and all MEDICAL information that may have been obtained or made including, but not limited to, all medical
records, alcohol, drug abuse and mental health records, billing records, pathology, radiology and laboratory reports,
consents, authorizations or waiver forms, and any other documentation. I understand that this information may
include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV
infection, Acquired Immune Deficiency Syndrome or AIDS related Complex) and any other communicable diseases. It
may also include information about behavioral or mental health services, and referral or treatment for alcohol and
drug abuse (as permitted by 42 CFR, Part 2).
3. The pu
rpose and need for such disclosure:
I understand that the Department of Licensing and Regulatory Affairs, Bureau of Professional Licensing and/or the
Department of Attorney General may use any information and records so released in connection with the
administration and enforcement of the laws of this State and of the United States.
4. I u
nderstand that if I give LARA permission I have the right to change my mind and revoke it. This must be in
writing to: Privacy Office, Michigan Department of Licensing and Regulatory Affairs, Investigations & Inspections
Division, 611 W. Ottawa St., Lansing, MI 48933. I also understand that LARA cannot take back any uses or
disclosures already made with my permission. Unless otherwise revoked or if I fail to specify an expiration date,
event or condition, this authorization will expire ONE (1) year from the signature date.
5. By signing this Authorization, I understand that any disclosure of information carries with it the potential for an
unauthorized re-disclosure and the information may not be protected by federal privacy rules. I further understand I
may request a copy of this signed authorization.
A copy
of this authorization shall serve in the stead of the original.
_____________________________________________________ ____________________________________
Patient/Client or Representative’s Signature Date Signed
(
If signed by a Legal Representative, relationship to the Patient/Client.
A letter of authority may be required)
_____________________________________________________ ____________________________________
Witness’ Signature Date Witnessed
____________________________________
Date Prepared
This authorization is acceptable to the Michigan Department of Licensing and Regulatory Affairs as compliant with HIPAA privacy regulations, 45 CFR, Parts 160 & 164, as modified
December 11, 2003. If you need assistance with reading, writing, hearing, etc., under the American’s with Disability Act, you may make your needs known to this Agency.
Completion: Voluntary Penalty: None Authority: P.A. 368 of 1978, as amended
State of Michigan
Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909-8170
BPL/IID-202 (12/18)
FILE NUMBER: