Fillable Complaint Form College of Physicians and Surgeons of

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Complaint Form College of Physicians and Surgeons of

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College of Physicians and Surgeons of British Columbia
300–669 Howe Street
Vancouver BC V6C 0B4
www.cpsbc.ca
Telephone: 604-733-7758
Toll Free: 1-800-461-3008 (in BC)
Fax: 604-733-3503
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Complaint Form
INSTRUCTIONS
1. Complete this form (and, if applicable, the Authorization for Representation form)
2. Ensure all signatures are authorized and additional documentation is provided
3. Mail the completed form to the College’s complaints department
The College reviews all complaints about physicians and/or surgeons licensed to practise medicine in British Columbia. All
complaints are treated in the same manner and assessed through the same review process.
All complaints are reviewed in the order they are received. Please be aware that the review process is detailed and can be
lengthy, depending on the circumstances. The length of time required for resolution will also vary. Once the College has
received your complaint, you will be notified through mail. This letter will contain contact information of the College staff
member responsible for your file. If at any time you would like an update on your complaint, please call this staff member
with your file number ready.
Before completing this form, please consider that the College is not able to:
• provide diagnoses or treatment recommendations, or direct the specifics of patient care
• direct or influence the payment of financial compensation to complainants
• adjudicate complaints without offering the physician(s) the opportunity to respond
• assist with concerns or complaints about hospitals, or other health-care providers such as nurses, pharmacists,
dentists, optometrists, psychologists, chiropractors, naturopaths, or any other health professional who is not a
registered physician or surgeon—these should be directed to the appropriate organization or regulatory authority
• contact the police on behalf of the complainant where illegal activities are suspected without the complainant’s
specific consent
CHECKLIST
Have you completed the following?
included the full name(s) and address(es) of the physician(s) involved
described the complaint in as much detail as possible
enclosed copies of documents that may support this complaint
provided your name and a telephone number where you can be reached during the day
signed and dated Authorization for Representation form, if applicable
signed and dated the Confirmation box (page 2)
checked that all five pages of this form are filled in and any separate sheets are attached
SUBMISSION
When you have completed this form, please send it by:
MAIL Complaints Department
College of Physicians and Surgeons of BC
300–669 Howe Street
Vancouver BC V6C 0B4
FAX 604-733-3503
If you would like more information about the College’s complaints process, please visit www.cpsbc.ca or phone
604-733-7758 or 1-800-461-3008 (toll-free in BC).
Thank you for taking the time to complete this form.
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College of Physicians and Surgeons of British ColumbiaComplaint Form
PERSON REGISTERING THE COMPLAINT
Title: Last name: Middle name: First name:
Address line 1: Address line 2:
City: Province: Postal code:
Home phone number: Preferred phone number:
I am the patient.
I am representing the patient for the purposes of this complaint and I have completed the Authorization for
Representation form.
Date of birth (YYYY-MM-DD): Personal health number:
My relationship to the patient is:
PATIENT INFORMATION (if different from above)
Title: Last name: Middle name: First name:
Address line 1: Address line 2:
City: Province: Postal code:
Home phone number: Preferred phone number:
Date of birth (YYYY-MM-DD): Personal health number:
Deceased
CONFIRMATION
Note: All complaints must be signed by the patient and/or patient's representative.
I have read and understand the following:
• I understand that the College of Physicians and Surgeons of British Columbia will obtain relevant medical records of the
patient as part of the investigation. The College will share some or all of the information and documents it receives
from the complainant and other parties to the physician(s).
• The information on this form is collected under the authority of the Health Professions Act, RSBC 1996, c.183. The
information provided will be used to process your complaint.
• If you have any questions about the collection or use of this information, please contact the complaints department at
the College of Physicians and Surgeons of British Columbia at 300–669 Howe Street, Vancouver BC V6C 0B4 or by
phone at 604-733-7758 or 1-800-461-3008 (toll-free in BC).
Patient's signature: Date:
Complainant's signature (if different from above): Date:
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College of Physicians and Surgeons of British ColumbiaComplaint Form
DETAILS OF THE PHYSICIAN(S)
Please identify the physician(s) you are filing this complaint about, and include an office address, if available. If you are
filing a complaint about more than two physicians, please continue on a separate sheet.
Note: A copy of this complaint may be sent to the physician(s) you have identified.
Physician's full name:
Address:
City: Postal code: Phone:
Date(s) attended:
Occurred at a: Office Hospital Other:
Have you tried speaking with this physician about your concern? Yes No
Physician's full name:
Address:
City: Postal code: Phone:
Date(s) attended:
Occurred at a: Office Hospital Other:
Have you tried speaking with this physician about your concern? Yes No
RELIEF SOUGHT
Please describe what you would like to see happen as a result of this complaint.
Note: The College has no legal authority to direct or influence the payment of financial compensation to
complainants.
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College of Physicians and Surgeons of British ColumbiaComplaint Form
DETAILS OF YOUR COMPLAINT
Please describe your concern in as much detail as possible. Be sure to include specific information of what occurred
between you and the physician(s), and the date and location of the incident(s). Please enclose copies of any documents
that you feel would be relevant to your case.
Note: A copy of this complaint may be sent to the physician(s) you have identified.
If needed, continue on a separate sheet. Check here if another sheet is attached.
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College of Physicians and Surgeons of British ColumbiaComplaint Form
DETAILS OF OTHER PHYSICIAN(S)
Please identify any other physician(s) who provided you with medical care relevant to your concerns. If there are more
than two physicians who may have information, please continue on a separate sheet.
Note: A copy of this complaint may be sent to the physician(s) you have identified.
Physician's full name:
Address:
City: Postal code: Phone:
Information details:
Physician's full name:
Address:
City: Postal code: Phone:
Information details:
DETAILS OF HOSPITAL(S)/CARE FACILITY(IES) ATTENDED
Please provide the names of the hospital(s) or care facility(ies) and date(s) you attended during this period. If there are
more than two hospitals, please continue on a separate sheet.
Note: It may be necessary for the College to obtain hospital or facility records as part of the investigation into this
complaint.
Hospital/care facility name:
City: Date(s) attended:
Hospital/care facility name:
City: Date(s) attended:
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Completed 29 October 2020

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