Fillable Complaint Form INSTRUCTIONS If you have a question (Collège Boréal)

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Complaint Form INSTRUCTIONS If you have a question (Collège Boréal)

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If you have a question or concern, we encourage you to rst speak with your doctor, the patient
advocate at your hospital or a College Public Advisor (1-800-268-7096 ext. 603). Please refer to the
CPSO’s Guide to the Complaints Process for assistance and more information.
To make a complaint, you may complete this form electronically, print it out and mail it to the
address at the end of this form, or submit it online to ir@cpso.on.ca.
Once the College has received your complaint, we will aim to contact you within two business days.
We are required to notify the doctor and may provide him/her a copy of your complaint.
Consent for the release of condential medical information
The investigator handling your complaint will need relevant personal health information.
The investigator may need to get written consent from you or the patient to get certain records.
Person Registering Complaint
Last name
Street
Daytime telephone
Email
Relationship to patient
I am the patient I am representing the patient for the purpose of this complaint
Alt telephone
City
First name
Apt#
Province Postal code
INSTRUCTIONS
Complaint Form
COMPLAINT FORM | PAGE 1
COMPLAINT FORM | PAGE 2
Patient Information if different from the complainant
Last name
Street
City
First name
Apt#
Province Postal code
Daytime telephone
Email
OHIP #
Alt telephone
Date of birth
Date of death (if deceased)
Obtaining Records
If you are the patient, your doctor is permitted, under the Personal Health Information Protection Act,
2004, to disclose your medical information to the CPSO so it can investigate.
If you are not the patient, the patient needs to sign a consent form or, if unable to do so, their legal
representative may sign this authorization form instead. This is necessary before the doctor can
provide the patient’s personal health records.
Preferred Mode of Communication
Doctor(s) You Are Complaining About
How would you like the College to communicate with you?
Telephone E-mail Regular mail Fax (if condential line)
Doctor Name Address Telephone Number
Summary of Concerns
Please list the key points of your complaint here.
1.
2.
3.
COMPLAINT FORM | PAGE 3
Describe Your Complaint
Please tell us in the box below:
• What happened
• Who was involved
• When and where it happened
• Any other information that may help the CPSO in its review
• What you hope will happen as a result of this complaint
COMPLAINT FORM | PAGE 4
*If more space is required, please attach additional printed pages.
E-MAIL ir@cpso.on.ca
or
MAIL The Registrar/CEO
College of Physicians and Surgeons of Ontario
80 College Street
Toronto ON M5G 2E2
By checking this box and submitting, I understand that I am complaining to the College of Physicians
and Surgeons of Ontario against a doctor. The doctor will be notied.
When you have completed this Complaint Form, please submit it:
Supporting Documents:
Please enclose or attach copies of any documents you feel would be relevent to your case. Please list any documents you
are providing so that we can be sure we have received everything.
Other Information
Please give the names of any other people who were involved and can provide information.
Name Contact Information
Their role/why they might have
information to contribute
COMPLAINT FORM | PAGE 5
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Complaint Form INSTRUCTIONS If you have a question (Collge Boral)

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Completed 19 October 2021

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