Board of Medicine
  • Complete the online complaint form.
    • Please note that the Description of Complaint field is limited to 2000 characters, which is approximately a half page of typed written text. If your description will be over 2000 characters, you can e-mail the description to Luann Brickei at luann.brickei@iowa.gov or attach a Word or PDF document to this form using the attachment function at the bottom of this webpage.

    • Fields marked by an * are required.

    • If this icon(button) is next to a field, you can click on this icon(button) to see a list of available choices or you can type your own text directly into the box.

    • Supporting documentation can be attached to this form by using the Attachment button at the end of the form.

    • When you have completed the form, click "Continue" button.

  • Download the complaint form, complete and mail to the board. Click here to download the form.

  • Mail or fax the complaint to the board. To mail or fax your complaint, provide the information that is requested in the online form in your written statement and mail to the board.

  • Questions? If you encounter any problems with this process or wish to speak to someone contact Luann Brickei at 515-242-3252 or luann.brickei@iowa.gov.

Person Registering Complaint

Name *
Address *
City *
State *
Zip Code *
Daytime Phone (xxx-xxx-xxxx) *
Cell Phone (xxx-xxx-xxxx)
E-mail
Date of Birth (mm/dd/yyyy) *
Gender *
Relationship to Patient *

Patient Information

Same as Complainant *
Address Same as Complainant Yes No
Name
Address
City
State
Zip Code
Daytime Phone
Date of Birth (mm/dd/yyyy)
Gender

Physician Information

Physician Name *
Address
City
State
Zip Code
Daytime Phone

Description of Complaint


(Limit of 2000 characters. Additional details can be attached to this form or emailed to Luann.Brickei@iowa.gov).
Description of Complaint *

Questions About Your Complaint


Each 'Details' field is limited to 2000 characters.

1. Did you discuss this complaint with the physician? * Yes No
Please provide details
2. Did you obtain an opinion form another physician about your complaint? * Yes No
Please provide details
3. Have you contacted an attorney or another regulatory agency about your complaint? * Yes No
Please provide details
4. Do you have/did you have a professional relationship (business, employment, etc.) with the health care provider? * Yes No
Please provide details
5. Do you have/did you have a personal relationship with the health care provider? * Yes No
Please provide details
6. What would you like the Board of Medicine to do about your complaint? *

Attachment

Attachment: Description: