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NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS 2000 Perimeter Park Drive Suite 160 Mooresville, North Carolina 27560 (919) 6788223PRACTITIONER COMPLAINT FORM INSTRUCTIONS 1)Please fill in the information
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How to fill out complaint form - practitioner

01
Start by providing your personal information such as name, contact details, and address.
02
Specify the details of the practitioner you want to file a complaint against, including their name, address, and any relevant identification numbers.
03
Clearly state the reason for your complaint and provide as much detail as possible, including dates, times, and any supporting documents or evidence.
04
Describe the impact or harm caused by the practitioner's actions or behavior.
05
If applicable, mention any previous attempts to resolve the issue and the outcome of those attempts.
06
Provide a clear and concise summary of what resolution or action you are seeking as a result of your complaint.
07
Read through the form thoroughly to ensure all required fields are completed and no important details are missing.
08
Sign and date the complaint form to certify the authenticity of the information provided.
09
Keep a copy of the completed form for your records.
10
Submit the complaint form to the appropriate authority, following any specified submission instructions or guidelines.

Who needs complaint form - practitioner?

01
Any practitioner who has experienced misconduct, negligence, or any other issue related to another practitioner can fill out a complaint form.
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Complaint form - practitioner is a form used to report misconduct or unprofessional behavior by a healthcare practitioner.
Any individual or organization who has experienced or witnessed misconduct or unprofessional behavior by a healthcare practitioner.
The complaint form - practitioner can be filled out either online or by printing and mailing the form to the appropriate regulatory board.
The purpose of the complaint form - practitioner is to hold healthcare practitioners accountable for their actions and protect the public from harm.
The complaint form - practitioner typically requires information such as the practitioner's name, details of the misconduct, date and location of the incident, and any supporting documentation.
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