Board of Chiropractic Examiners
State of Arizona

Complaint Web Form

Please provide your name, address, daytime telephone number, as well as the name and address of the chiropractor. While we do not wish to complicate the filing of complaints, we ask that you please provide as much detail as you can regarding all facts which relate to the complaint, including treatment dates, references to records which you may have or know about, and any attempts you may have already made to resolve your complaint with the provider. The information requested is essential in conducting a thorough investigation of the allegations. Failure to provide needed information may result in the return of your complaint form. You may include as many pages of comments and supporting documents as you feel are necessary.

Although the Board accepts anonymous complaints, state law requires that you provide your name. Your identity will be kept confidential from the public however the Board may be compelled to release your name to the doctor involved in your complaint. Upon receipt of your complaint, a copy will be sent to the chiropractor with instructions to respond in writing. A copy of the chiropractor’s written response will be mailed to you for your review and at that time, you may provide additional comments to the Board. Your complaint will be placed on a future agenda for the Board to review and determine what action, if any, is necessary. You will be notified of the Board’s meeting date, time, and location and are welcome to attend and discuss the complaint with the Board.

 

Complaint Information
Please provide your First and Last Name.
Mailing Address
Please provide an address where the Board can contact you regarding this complaint.
Nature of Complaint
I am requesting reimbursement of fees paid to the licensee, if the Board determines that a violation of the law did occur in this case.
$
I am requesting reimbursement of up to this amount, if the Board determines that a violation of the law occurred. Please note the Board has full discretion to award reimbursement in this matter.
Chiropractic Physician's Information
Narrative of the Complaint
If you have additional information or documents you wish to provide the Board, please attach them here.
More information
  • Files must be less than 10 MB.
  • Allowed file types: gif jpg jpeg png bmp eps pict psd txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods avi mov mp3 ogg wav.
Authorization and Request
I hereby request the State of Arizona Board of Chiropractic Examiners to investigate my complaint against the above named Doctor of Chiropractic. I understand and agree that I may be called to testify under oath to the information given in this complaint, should the Board request me to do so.