Disciplinary (public) documents request form

* indicates a required field

Licensee information:


Requester information:


Documents requested:

NOTE: All disciplinary actions are also available online - Public Log File

All disciplinary (public) documents
Other (public†) (please specify)

†Some information is confidential pursuant to state law: patient complaints, malpractice/lawsuit information, investigations


Yes
No

How do you want the documents delivered:


Email to address below
Mail to address above - NOTE: Only option if you want certified copies.



 

This form uses Huggins' Email Form Script

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