NY DOH-3867 2011 free printable template

See attached Instructions before completing INFORMATION ABOUT YOU Name Address Last First No. and Street Telephone City Day MI State Zip Code Evening Please provide a number where you can be reached PHYSICIAN OR PHYSICIAN ASSISTANT COMPLAINT Describe your complaint as completely as you can. Please sign and date the form. Patient s Name Date of Birth Month Year When did this happen Have you filed a complaint with anyone else If yes with whom DOH-3...

How to fill out NY DOH-3867

How to fill out NY DOH-3867

1. Obtain the NY DOH-3867 form from the New York State Department of Health website or local office.
2. Fill in the applicant's name, address, and contact information in the designated sections.
3. Provide the details of the healthcare facility or provider in the appropriate fields.
4. Specify the type of health care services being requested.
5. Include any required documentation or supporting materials as stated in the form instructions.
6. Review the completed form for accuracy and completeness.
7. Sign and date the form as required.
8. Submit the filled-out form to the appropriate department via mail or online, if applicable.

Who needs NY DOH-3867?

1. Individuals seeking to authorize a healthcare provider to access their health records.
2. Patients who wish to grant permission for the release of their medical information.
3. Healthcare professionals needing to ensure compliance with health information privacy regulations.
4. Family members or legal guardians who need to manage the health information of a minor or incapacitated individual.

People Also Ask about

How do I complain about a local pharmacy?

Each pharmacy must have a complaints manager. Their chief executive or a partner must act as the 'responsible person' who makes sure complaints are dealt with properly. You can complain by letter, email or by talking to someone at the pharmacy.

How do I file a complaint with NYS Dept of health?

Phone. 1-800-663-6114 - Complaints/Inquiries (Monday-Friday 9:00 a.m - 5:00 p.m.)

How do I report a doctor in NY?

Doctor Complaint Agency: New York State Department of Health. Division: Professional Medical Conduct. Phone Number: (800) 663-6114. Business Hours: Monday - Friday: 8 AM - 4:45 PM.

What is the example of complaint?

I wish to complain about _ (name of product or service, with serial number or account number) that I purchased on _ (date and location of transaction). I am complaining because _ (the reason you are dissatisfied). To resolve this problem I would like you to _ (what you want the business to do).

How do you make a proper complaint?

How to write an effective complaint letter Be clear and concise. State exactly what you want done and how long you're willing to wait for a response. Don't write an angry, sarcastic, or threatening letter. Include copies of relevant documents, like receipts, work orders, and warranties.

How do I fill out a complaint form?

0:31 2:02 Learn How to Fill the Complaint Form - YouTube YouTube Start of suggested clip End of suggested clip Next. You must provide your name as the plaintiff. And the names of any other individuals you may beMoreNext. You must provide your name as the plaintiff. And the names of any other individuals you may be representing as Co plaintiffs such as minor children or dependents.

How do I file a complaint with NYS Dept of Health?

Phone. 1-800-663-6114 - Complaints/Inquiries (Monday-Friday 9:00 a.m - 5:00 p.m.)

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What is NY DOH-3867?

NY DOH-3867 is a form used to report and document certain health information as required by the New York State Department of Health.

Who is required to file NY DOH-3867?

Individuals or entities involved in specified health-related activities, such as healthcare providers or organizations, are typically required to file NY DOH-3867.

How to fill out NY DOH-3867?

To fill out NY DOH-3867, one must complete the required fields accurately, providing necessary documentation and following the instructions provided with the form.

What is the purpose of NY DOH-3867?

The purpose of NY DOH-3867 is to collect important health data for monitoring public health and ensuring compliance with state health regulations.

What information must be reported on NY DOH-3867?

The form requires reporting information such as specific health conditions, patient demographics, treatment details, and any other relevant health data mandated by the New York State Department of Health.