I am Making a Complaint on Behalf of Someone Else

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"*" indicates required fields

1Consent Form
2Your Information
3Patient Information
4Physician Information
5Main Concerns
6Other Information
7Finalize & Submit
The investigation process generally requires the collection of the patient’s personal and confidential health information. The College requires documentation confirming your authority to represent the patient and receive such information on their behalf.

Please download the Consent Form and choose from one of the sections (A, B or C) that best describes your authority. Depending on the circumstances, the level of documentation required to support your authority may vary. Enclosing the appropriate documentation will allow the College to process your complaint faster.

If you are concerned about medical care received by another person, but do not have that person’s consent to file a complaint, you can contact the College to discuss your concerns. Please note that the College cannot provide details about a patient’s personal health information to a third-person complainant, but will review and take appropriate action on all concerns raised.

If you have questions about how to complete the consent form, please contact the College’s Professional Conduct Coordinator at 709-726-8546 or by email, complaints@cpsnl.ca

Once completed, upload the consent form, and any supporting documentation by using the "Select Files" button below.

Drop files here or
Accepted file types: pdf, jpeg, jpg, Max. file size: 64 MB.
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    Please upload completed Consent Form and Will or Power of Attorney, if applicable.

    Mailing Address*
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    I would like to receive correspondence from the College by:*
    MM slash DD slash YYYY
    If you are filing a complaint against more than one physician, please complete a separate complaint form for each physician.

    Description of the Incident

    Please be as detailed as possible and provide information in paragraph form.
    Please indicate the exact action(s) that the physician did OR did not do that is causing you to make this complaint. This summary is required to help the College better understand your concerns and process your complaint efficiently.

    PLEASE LIST YOUR CONCERNS IN POINT FORM.

    Additional Documents

    If applicable, please list any additional information (i.e., written correspondence, audio recording, etc.) in your possession, that may be relevant to your complaint. The College's investigator will contact you if the additional information is necessary for their investigation.

    Witnesses

    List any people who may have information about this complaint. You are not required to have a witness to make a complaint. NOTE: Please ensure that each witness is aware that the College may contact them as part of the investigation of your complaint.

    Follow-up Action

    Describe any steps you may have taken to resolve your complaint.
    I declare that I am the person identified as the "complainant" and that I am making a formal complaint against the physician named in this form.*

    I declare that the information provided in this form is true and accurate to the best of my knowledge.*

    I understand that the physician named in this complaint will be sent a copy of this form and all relevant information gathered during the investigation of my complaint.*

    I understand that if my complaint leads to a hearing - or the Committee's decision is appealed to a court of law - information relating to my complaint must be disclosed and I may be called to testify as a witness.*

    I understand that if I do not fully complete this form or participate in the investigation, my complaint may be dismissed for lack of information.*

    I agree to engage in respectful communication with any individual involved in the College’s complaint process, including College staff and the respondent physician.*

    MM slash DD slash YYYY
    This field is for validation purposes and should be left unchanged.
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