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Submit a Complaint for an Unlicensed Person or Facility

Your complaint is critical to the mission of the Kansas State Board of Healing Arts (“Board”) as it assists us in protecting the public by informing us of any possible violations.

The Board has jurisdiction over the following persons licensed in Kansas:

MD (Medical Doctor)PA (Physician Assistant)OTA (Occupational Therapist Assistant)
DO (Osteopathic Doctor)PT (Physical Therapist)RT (Respiratory Therapist)
DC (Chiropractor)PTA (Physical Therapist Assistant)AT (Athletic Trainer)
DPM (Podiatrist)LRT (Radiologic Technologists)LAc (Licensed Acupuncturists)
ND (Naturopathic Doctor)OT (Occupational Therapist)Independent Certified Nurse Midwives (CNM-I)
Contact Lens DistributorsCorporate Practice of Medicine (CPM)

Please print or type legibly. Please furnish all identifying information (to include full names and addresses) for all licensees, complainants, patients, and facilities involved in the complaint.

Additional pages may be added if necessary. Attach copies of any documents you have concerning the allegations.

Do not send the originals or your only copy of any document because we cannot return your documents.

The Board does not represent individuals, nor obtain compensation on behalf of individuals. Each person is free to seek legal representation if they believe it is necessary. Board investigations and reviews are not subject to discovery by private litigants. Only public action will be disclosed to the complainant and/or the public.

In certain circumstances, a copy of your complaint may be provided to the Licensee identified in your complaint for a review and response to the Board.

The Board is required to review all complaints received. Once submitted, the complaint generally cannot be rescinded.

If you have any questions regarding the functions of the Board, please call (785) 296-7413.
Individual or Facility Involved in Complaint
 
Full Name:  
License Number:  
Profession:  
License Type:  
 
Practice Name:  
Practice Address:  
Practice Phone:  
 
Tell us about Yourself
 
Full Name:  
Contact Name:  
Address:  
Phone:  
Fax:  
Email:  
 
Patient information is required for us to be able to accurately investigate any complaint.
 
Patient Full Name:  
Address:  
Date of Birth:  
SSN (if known):  
Phone:  
Email:  
 
Friend or Relative who will know your most current address and phone number
 
Friend\Relative Full Name:  
Address:  
Phone:  
Email:  
 
Witness to the Incident
 
Witness Full Name:  
Address:  
Phone:  
Email:  
 
Detailed Complaint Deccription

You will be contacted by the Board if clarification or additional information is needed, please provide a concise account of your major concerns related to the Licensee listed on your complaint form. Please describe in detail all allegations against the practitioner(s) including specific dates of service. When formulating your narrative, remember to include details specific to your allegations such as the who, what, when, and where. Use additional sheets if necessary.

I acknowledge that the Kansas Board of Healing Arts may provide a copy of this form to the person against whom the allegations are made.

I agree to testify in any hearings which may arise as a result of these allegations. The statements I have made are true and correct to the best of my knowledge and belief.
DATE:   SIGNED: