I am Making a Complaint on Behalf of Someone Else

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.

Upload Documents*

Drop files here or

Accepted file types: pdf, jpeg, jpg, Max. file size: 64 MB.

Please upload completed Consent Form and Will or Power of Attorney, if applicable.

Full Name*

Preferred Name

Pronouns

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone*

Mobile Phone

I would like to receive correspondence from the College by:*

Email

Letter Mail

Patient's Full Name*

Patient's MCP Number*

Patient's Date of Birth*

Patient's Family Physician or Primary Care Provider (Full Name)

Physician's Full Name*

If you are filing a complaint against more than one physician, please complete a separate complaint form for each physician.

Where Did the Incident Take Place? (clinic, hospital, office, etc.)*

Incident Date(s)*

Description of the Incident

Please be as detailed as possible and provide information in paragraph form.

Description of the Incident/Behaviour that Concerns You*

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.

Concern 1*

Concern 2 (if applicable)

Concern 3 (if applicable)

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.

Witness Name

Witness Contact Info (phone/email)

Connection to Patient/Complaint

How They Were Involved

Witness #2 Name

Witness #2 Contact Info (phone/email)

Witness #2 Connection to Patient/Complaint

How They Were Involved

Follow-up Action

Describe any steps you may have taken to resolve your complaint.

Follow Up Action

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.*