1319 Robert C. Byrd Drive

Name and address of dentist or hygienist against whom complaint is made:

(Street address if known)

WV Dental License Number

NATURE OF COMPLAINT IN DETAIL: Provide specific information regarding date and nature of event(s) if known. Attach additional pages and supporting documentation as needed.

PROVIDER INFORMATION:

Provider:

Address:

CLIENT/PATIENT INFORMATION:

Name: Date of Injury: 

Address: Date of Birth:

Social Security Number:

PURPOSE OF DISCLOSURE:

Complaint Process Legal Process

Other (specify):

INFORMATION TO BE RELEASED:

Dental History/Examination Dental Radiographs Dental/Surgical Reports

Medical History/Examination Medical/Surgical Reports E/R Records

Radiology Reports Laboratory Reports Entire Record

Consultations Discharge Summary

Other (specify):

Specific Dates Needed:

YOUR RIGHTS AND OBLIGATIONS WITH RESPECT TO THIS FORM:

I understand that:

1. I may refuse to sign this authorization and that it is strictly voluntary.

2. My treatment, payment, enrollment or eligibility for benefits may not be conditional on signing this authorization.

3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.

4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by the federal privacy regulations and may be re-disclosed.

5. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.

6. I get a copy of this form after I sign it.

AUTHORIZATION EXPIRES: THIS AUTHORIZATION WILL REMAIN IN FORCE FOR 6 MONTHS.

I have had an opportunity to review the contents of this authorization and my rights in relation to this form. By signing below, I am certifying my agreement with the statements made in this form and agreeing to the release of my protected health information as indicated by this form to the West Virginia Board of Dental Examiners, PO Box 1447, Crab Orchard, WV  25827. Telephone Number (877)914-8266, (304)252-8266, Fax Number (304)253-9454.

SIGNATURE OF PATIENT DATE

Questions about completion of this form or about the disciplinary process may be directed to:

NOTE: THE LICENSEE IS NOTIFIED WHEN A COMPLAINT IS FILED AGAINST HIS/HER LICENSE. A COPY OF THE ORIGINAL COMPLAINT FORM AND ALL SUPPORTING DOCUMENTS ARE SENT TO THE LICENSEE WITH A LETTER OF NOTIFICATION.

Name, address and telephone number of individual making complaint.

Name: TITLE

Facility/Agency:

Address:

Telephone: FAX:

Date