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DIAL Complaint Form: Board of Medicine

One of the most important ways the department protects consumers is by investigating their complaints against physicians. Please provide the following information so that we 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

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

Name of Clinic or Hospital where care occurred

Approximate date or date range of care

Name of Clinic or Hospital where care occurred

Approximate date or date range of care

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 personal relationship with the physician?

If yes, please explain.

Recaptcha Response

Be sure to verify that you are not a robot by using the Captcha tool at the below.

If you have records or other documentation you wish to submit with your complaint, please email those documents to IBMComplaints@iowa.gov.

Please include your name (complainant name) as well as the physician's name on whom you've filed the complaint.

DIAL Complaint Form: Board of Medicine

Complainant Information

Complainant's Name

Complainant's Full Address

Patient Information

Patient's Name

Patient's Address

Patient's Date of Birth

Physician Information

Physician 1 (Name)

Physician 2 Name

Physician 3 Name

Complaint Information

Questions About Complaint