The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
Professional Discipline Complaint Form
Instructions for Completing Complaint Form
To complain about service or treatment by a licensed professional, or about illegal practice of a profession by an unlicensed person, complete
the COMPLAINT form on page 2. Please note that we do not have authority to investigate fees you believe are too high or to intervene in fee
disputes. However, we can investigate complaints involving fraudulent billing.
Type or print clearly in black ink. Describe your complaint as completely as you can. If you do not have a daytime telephone number, it is
helpful if you can provide a number where a message can be left for you during the day. If you have any papers that may support your
complaint, such as bills or correspondence, please attach copies. Do not send originals. If you have physical evidence, such as incorrectly
dispensed medications, it is important for you to retain that evidence in its original condition.
Be sure to sign and date your complaint. Send it to one of the regional Offices of Professional Discipline. When your complaint is received, it
will be assigned to an investigator who will contact you in writing or by telephone. You will have an opportunity to explain your complaint in
more detail. If we do not have the authority to investigate your complaint we will refer it to the appropriate agency.
Also, complete the AUTHORIZATION portion of this form by entering your name and the name of the practitioner and/or hospital in the
appropriate spaces. The Authorization directs the professional, hospital, or other facility to release information about your treatment or the
services rendered to you. Sign and date the Authorization, and have it signed and dated by a witness. A witness can be any person 18 years
or older. The Authorization does not have to be notarized. Please note that if you leave the Authorization blank, it may delay the investigation
of your complaint.
IMPORTANT! Complaints against physicians (general practitioners, internists, cardiologists, gynecologists, pediatricians, urologists, surgeons,
radiologists, oncologists, anesthesiologists, ophthalmologists, orthopedists, and others) should be sent to: New York State Department of
Health, Office of Professional Medical Conduct, Riverview Center, 150 Broadway, Suite 355, Albany, NY 12204. ALL OTHER COMPLAINTS
Office of Professional Discipline
Regional Offices
80 Wolf Road, Suite 204, Albany, NY 12205, Telephone: 518-485-9350, Fax: 518-485-9361
2400 Hasley Street, Bronx, NY 10461, Telephone: 718-794-2457 or 2458, Fax: 718-794-2480
Brooklyn, Staten Island
9 Bond Street, 4th Floor, Brooklyn, NY 11201, Telephone: 718-722-2587, Fax: 718-722-2840
295 Main Street, Suite 924, Buffalo, NY 14203, Telephone: 716-842-6550, Fax: 716-842-6551
Central Administration
1411 Broadway, 10th Floor, New York, NY 10018, Telephone: 212-951-6400, Fax: 212-951-6420
Long Island
250 Veterans Memorial Highway, Room 3A-15, Hauppauge, New York 11788, Telephone: 631-952-7422, Fax: 631-952-1029
163 West 125th Street, Suite 302, New York, NY 10027, Telephone: 212-961-4369, Fax: 212-961-4361
Mid-Hudson Region
One Gateway Plaza, 55 S Main Street, 3rd floor, Port Chester, NY 10573, Telephone: 914-934-7550, Fax: 914-934-7607
85 Allen Street, Suite 120, Rochester, NY 14608, Telephone: 585-241-2810, Fax: 585-241-2816
333 East Washington Street, 2nd Floor, Suite 211, Syracuse, NY 13202, Telephone: 315-428-3286, Fax: 315-428-3287
Professional Discipline Complaint Form, page 1 of 2, Rev. 11/20
Information About You
City State Zip Code County
Daytime Telephone
Evening Telephone
Information On The Person(s) You Are Complaining About
Name of Hospital/Business/Store (if applicable)
City State Zip Code County
Describe your complaint here. Be specific. What happened? When? Where? Type or use black ink. Use additional sheets if necessary.
Please read the instructions on page 1 carefully before describing your complaint.
To the best of my knowledge, the information in this complaint is true and complete.
Signature Date
Check here if you have included additional sheets or other material.
I, (print your name here) , request and authorize
the above-named licensed professional or practitioner and/or any other licensed professional or practitioner, and the above-named hospital or
facility and/or any other hospital or facility, to disclose fully to the New York State Education Department and its authorized representatives all
information and records relating to the diagnosis, treatment, prognosis made for and/or on my behalf, or service rendered for and/or on my
behalf, by the said licensed professional, practitioner, hospital, or facility.
Name of practitioner(s)
Name of hospital(s) or other facilities
Your Signature Date
Signature of witness Date
Professional Discipline Complaint Form, page 2 of 2, Rev. 11/20