Iowa Board of Medicine Complaint Form

One of the most important ways the Iowa Board of Medicine protects consumers is by investigating their complaints against physicians. This form helps the Board collect basic information to review your complaint. For an explanation of the complaint investigation process, please visit the Board's Enforcement page of the website, at https://medicalboard.iowa.gov/physicians/enforcement or call 515-281-5171. Please provide the following information so that the Board can acknowledge receipt of your complaint and contact you should additional information be needed:

Complainant Information

Your Daytime Phone Number

Patient Information

Patient's Daytime Phone Number

Patient's Email

Patient's Gender

Patient's Race/Origin/Ethnicity

Other - Description

Patient's Race/Origin/Ethnicity

Relationship of Complainant to Patient

Description of Relative (ie. sibling, child, parent, etc)

Physician Information

Please provide the following information about the physician(s) who is the subject of your complaint:

Name of Clinic or Hospital where care occurred

Approximate date or date range of care

Physician 1 (Office Phone Number)

Name of Clinic or Hospital where care occurred

Approximate date or date range of care

Physician 2 Phone Number

Name of Clinic or Hospital where care occurred

Approximate date or date range of care

Physician 3 Phone Number

Complaint Information

Please describe the complaint, including dates and issues.

Questions About Complaint

Did you discuss the complaint with the physician?

Explain what was discussed

Did you obtain an opinion from another physician about your complaint?

Explain about the opinion from another physician

Have you contacted another regulatory agency or an attorney about your complaint?

If yes, please explain.

Do you have/did you have a professional relationship (business, employment, etc.) with the physician?

If yes, please explain.

Do you have/did you have a personal relationship with the physician?

If yes, please explain.