Instructions for Completing Complaint Form

To file a complaint about a physician (M.D. or D.O.), P.A. or Specialist Assistant licensed to practice medicine by the State of New York, please complete this form and mail the original to the NYS Department of Health, Office of Professional Medical Conduct, Riverview Center 150 Broadway, Suite 355 Albany, New York 12204-2719.

If you have any questions regarding the filling out of this form, please contact OPMC at: (800) 663-6114 or (518) 402-0836.

Trained staff will review the information you submit. OPMC will investigate all matters of possible professional misconduct. If your complaint requires the attention of another office, it will be sent to the office authorized to address your concerns.

To help us review your complaint, please do the following:

• Type or print clearly in ink.
• Describe your complaint completely.
• Include the names of any witnesses.
• Include the names of other agencies with whom you filed a complaint.
• Attach additional pages if necessary.
• Attach copies of supporting documents. Do not send originals.
• Sign and date the form