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Hawkeye-X - 14 Jul 2006 01:40 GMT

I have in my hand an official complaint form from Georgia Board of
Medical License.

Care to shut up now before I mail it in? You have 24 hours.

Here is a sample letter:

08/04
COMPLAINT FORM

Person(s) Requesting Investigation Person To Be Investigated

______________________________________
______________________________________
Name Physicians Full Name (First and Last)

______________________________________
______________________________________
Address Physicians Address

______________________________________
______________________________________

______________________________________
______________________________________
Phone Number Physicians Phone Number

(Give a brief statement of the facts with dates. Use additional
sheets as necessary with copies of relevant documents. PLEASE SEND
COPIES ONLY. MATERIALS WILL NOT BE RETURNED.)

PATIENTS FULL NAME: _______________________________________________
(It would be helpful if you could include the patients date of birth
and Social Security number.)
DATE OF BIRTH ____________________ SOCIAL SECURITY NUMBER
_____________________

I authorize the Georgia Composite State Board of Medical Examiners to
use this form and the information submitted with this form when
conducting an investigation or acquiring medical records. I hereby
authorize the Board to release a copy of my complaint to the physician
involved/mentioned in the complaint.

Signature of Person Requesting Investigation Date
Mail to: Composite State Board of Medical Examiners, 2 Peachtree St,
NW. 36th floor, Atlanta, GA 30303.

08/04
Waiver Form

I, _____________________________________________________________,
having filed a
            (Complainants Name)

complaint with the Georgia Composite State Board of Medical Examiners
dated

______________________________against__________________________________who
is licensed as a
                        (Licensees Name)

______________________________.
(License Type)

Hereby waive any privilege which I may have with respect to the
licensee against whom I have made complaint, so that the licensee may
respond to my complaint and provide confidential information to the
Board pertaining to the matters raised in my complaint, and

Authorize the release of the information in my complaint to those
individuals who, in the sole discretion of the Board, its staff or
legal counsel, may be necessary to conduct a full and fair
investigation of the complaint, and

Authorize the use of my name in the investigation of my complaint by
the Board, its professional staff, investigators, and legal counsel,
and

Hereby give my consent for the Georgia Composite State Board of
Medical Examiners to be given access to any and all of my personal,
medical/psychiatric/psychological/alcohol treatment/drug treatment
records for review and copying.

This consent is subject to revocation at any time upon written notice
by the patient named herein to the above custodian of record, except
to the extent that action has been taken in reliance upon this
consent.

RETURN TO:

Composite State Board of Medical Examiners
Attn: Complaints Unit
2 Peachtree Street, N.W., 36th Floor
Atlanta GA 30303
Phone: (404) 657-6487

I authorize the Georgia Composite State Board of Medical Examiners to
use this form if contacting the physician and/or conducting an
investigation.

____________________________________
___________________________________________
Signature                        Date