Maine Board of Licensure in Medicine Email Complaint Form
You may use this electronic form to file a complaint against a licensee (a physician or a physician's assistant). Please note that the Maine Board of Licensure in Medicine has no authority to assist you with fee disputes with your licensee, unless the licensee is demanding payment for services not rendered. If you have a complaint concerning a fee dispute, please contact the Maine Attorney General's Office, Consumer Protection Unit, at http://www.state.me.us/ag/consumer.htm

Person Registering Complaint
Please provide the following information so that we may acknowledge receipt of your complaint and that we may contact you should we need further information.
The submission of this form does not provide us with your Email address.

Your
Name:

First	Middle	Last

Address:

City:

State:

Zip Code:

Daytime Phone:

Include Area Code

Complaintant's Date of Birth:

If you wish you may provide an Email address.
Your Email address is

Patient Information

Is the patient information the same as the complainant information?
If patient information is NOT the same as the complainant information please provide the information below.

Patient's
Name:

First	Middle	Last

Address:

City:

State:

Zip Code:

Daytime Phone:

Include Area Code

Patient's Date of Birth:

Complaint Filed Against

Please supply specific information regarding the licensee (physician or physician's assistant) you are filing a complaint against, to include the licensee's full name and practice location.

Licensee's
Name:

First	Middle	Last

Is the Licensee a

Address:

City:

State:

Zip Code:

Daytime Phone:

Include Area Code

Note: If you are filing a complaint against several licensees, you must send each one separately. To do this, complete this form, send it and then back up and fill out the information for the next licensee. The rest of the information will still be filled in.

Narrative Information
Provide detailed information regarding your complaint to include date(s) of treatment.

If you should encounter any problems with this process, or wish to speak to someone, please contact Tim Terranova by email by clicking here, or call him at (207) 287-3608.