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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 Julie Best by email by clicking here, or call her at (207) 287-3608.