Should you have technical difficulty submitting from this site, you may contact us with details or you may use the printable form available
here
.
Email:
enfcomplaints@dhp.virginia.gov
 
Person Supplying Information
Submit Anonymously
ATTENTION: The Department of Health Professions cannot guarantee anonymity. A copy of your complaint and any supporting documentation provided by you may be shared with the subject of the complaint (practitioner or licensee) pursuant to the Code of Virginia § 54.1-2400.2 (G). Using the online complaint form may help preserve your anonymity.
If you wish to submit an anonymous complaint, please ensure you do not include any information on the complaint form or supplemental documents that reveals your identity.
While the Department accepts anonymous complaints, our ability to evaluate and investigate complaints often depends on the level of detail provided in the initial complaint. When you file a complaint anonymously, the Department will not be able to follow up with you for more information. Therefore, please provide as much detail as you can in your complaint. Without sufficient detail, to include patient-specific information, dates of service, and other relevant information, the Department's ability to investigate your concerns may be significantly limited.
Title
First Name
Middle Initial
Last Name
Business Name (If Applicable)
Address 1
Address 2
City
State
select
(Not Specified)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands of the U.S.
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Home Phone
Work Phone
Fax Number
Email Address
Relationship to the Practitioner
select
(Not Specified)
Patient/Client
Patient/Client's Relative/Friend
Co-Worker
Supervisor
Other (Specify)
  
Subject of Report (Practitioner or Facililty you wish to complain about)
NOTE: If you would like to complain about more than one practitioner, you will need to submit a separate complaint form for each individual/entity you would like to complain about.
Title
First Name
*
Middle Initial
Last Name
*
License Type (e.g. M.D., RN, DDS, etc.)
License Number
Business or Facility Name (If Applicable)
Address 1
Address 2
City
State
select
(Not Specified)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands of the U.S.
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Home Phone
Work Phone
Fax Number
Email Address
Note:
Asterisk (
*
) signifies a required field. Put N/A if the field does not apply or if you are unable to answer any required field. If filing on a facility regulated by DHP (e.g. pharmacy, veterinary establishment, funeral establishment) answer N/A for first and last name and type the name of the facility into the Business Name field.
Please provide specific information when completing the details requested below. Failure to provide specific information will limit the department's ability to investigate your concerns.
Patient Information
Same As Person Supplying Information above.
No Patient Information
No patient information specified.
First Name
*
Middle Initial
Last Name
*
Date of Birth (M/d/yyyy)
Address 1
Address 2
City
State
select
(Not Specified)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands of the U.S.
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Home Phone
Work Phone
Fax Number
Email Address
Note:
At least some of this information must be filled in or we cannot verify your complaint.
Details of Report
*
What did the practitioner do or fail to do? Include specific details: Who, What, Where, When.           Characters Remaining:
4000
Should the space below be insufficient to hold the details of your complaint, there will be an opportunity to add attachments on a later page.
Note:
Asterisk (
*
) signifies a required field.
The Patient/Client sustained injury or harm as a result of the licensee's Actions.
Please Explain.           Characters Remaining:
2000
I have contacted the Licensee regarding my concerns.
Please tell us when and describe the Licensee's response.           Characters Remaining:
2000
My concern or incident is related to a facility, private office, home, etc.
Please provide specific names and addresses of each place involved with your concern/incident.           Characters Remaining:
2000
Who else has knowledge of these events? Please provide full names and contact information.           Characters Remaining:
2000
I have reported this complaint to another agency or court.
Please tell us when and provide names, addresses, and telephone numbers of those contacts.           Characters Remaining:
2000
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