Online Complaint Form

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Today is:

TO:	Mississippi State Board of Physical Therapy P.O. Box 55707 Jackson, MS 39296-5707 Phone: (601) 352-2918 Fax: (601) 352-2920 Email: sboyette@msbpt.ms.gov
Your Information: * Required Fields
	*Name First, Last:
Home	*Address:
Home	City, State * Zip:
Home	*Phone:

Work	Address:
Work	City, State Zip:
Work	Phone:

Name and address of the PT(s) or PTA(s) whom you are filling a complaint against:
	Name:
	Address:
	City, State Zip:
	Phone:

Your relationship to the person accused of wrongdoing: (check one)
	Patient
	Co-Professional
	Other: (Please explain)

1. Please provice a detailed chronological statement of your complaint, including dates, times, places, supporting documentation, etc. (Please try to be as specific as possible) Scanned copies of letters, reports, notes, and other correspondence, contracts, witness statements and drawings can be emailed by clicking here or you can mail COPIES ONLY to the address above.)


2. Please provide names, addresses and telephone numbers of witnesses or other persons with knowledge of this situation , including other professionals who could also provide information.



3. Please provide copies of any documents relevant to your complaint such as letters, reports, patient records, notes, correspondence, contracts, witness statements, drawings, video footage and any other supporting documentation. Scanned copies of letters, reports, notes, and other correspondence, contracts, witness statements and drawings can be emailed by clicking here or you can mail COPIES ONLY to the address above.)

4. Please reference the provisions of the Physical Therapy Act, and/or Rules and Regulations which you feel have been violated by the alleged wrongdoing.

5. Please check this box to indicate that you understand that a Board representative or the Board attorney may contact you to discuss this matter in more detail.

6. Please check this box as your electronic signature for the following: I ATTEST THAT ALL STATEMENTS MADE BY ME IN RELATION TO THIS COMPLAINT ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.