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Submit a Complaint for an Unlicensed Person or Facility

Your complaint is very important to the Kansas State Board of Healing Arts (“Board”) as it is critical in assisting us in protecting the public and informing us of any possible violations.

Please furnish all identifying information for the complainant, the patient and all practitioners and facilities involved in the complaint. When providing your address, the address of the patient or the practitioner, list the street address, not a post office box.

The Board will not perform investigations to benefit a personal litigation case or act as your attorney. The Board does not obtain monetary compensation on behalf of an individual or engage in dispute resolution. If you believe you have been damaged or lost money as the victim of a licensed or unlicensed individual, you are free to contact your personal attorney regarding recovery options.

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.

We only have authority over the individuals we license:
MD (Medical Doctor)PA (Physician Assistant)OTA (Occupational Therapist Assistant)
DO (Osteopathic Doctor)PT (Physical Therapist)RT (Respiratory Therapist)
DC (Chiropractor)PTA (Physical Therapy Assistant)AT (Athletic Trainer)
DPM (Podiatrist)LRT (Radiologic Technologists)LAc (Licensed Acupuncturists)
ND (Naturopathic Doctor)OT (Occupational Therapist)Contact Lens Distributors
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

Please describe in detail all allegations against the practitioner(s). Describe each incident with specific dates and list any witnesses.

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: