Massachusetts General Law, Chapter15224713(3), requires the Health Care Services Board to receive and investigate compensation claim s, where the providers are alleged to have engaged in patterns of: (i) discrimination against compensation claimants; (ii) over - utilization of procedures; unnecessary surgery or other procedures; or (iv) other inappr opriate treatment of compensation recipients Where the Health Care Services Board finds a pattern of abuse, it shall refer its findings to the appropriate Board of Registration. Please check ( ) the appropriate box above to indicate the category t o which this complaint relates. TO FILE A COMPLAINT, PLEASE PROVIDE THE FOLLOWING INFORMATION: ABOUT THE PERSON FILING THIS FORM: YOUR NAME: ADDRESS: CITY: STATE: ZIP COD E: YOUR RELATIONSHIP TO THE COMPLAINANT: YOUR FIRM, COMPANY OR EMPLOYER: ABOUT THE HEALTH CARE PROVIDER: SPECIALTY (if known): ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE: ( ) THE DATE(S) OF THIS INCIDENT: Using the following space, summarize your complaint about this health care provider in 50 words or less . In addit ion , attach a detailed narrative of your complaint to this form describing the treatment(s), procedure(s), date(s), location(s), a nd other fact s relevant to the complaint. Was this an impartial examination ordered by the Department of Industrial Accidents? YES NO Was this a health care service performed by the treating health care provider, YES NO or a service performed by a provider chosen by an insurer or employer? YES NO Reproduce as Needed Revised 7/20 1 9 Page 1 of 2 The Commonwealth of Massachusetts Department of Industrial Accidents Lafayette City Center, 2 Avenue de Lafayette Boston, Massachusetts 02111 HEALTH CARE PROVIDER COMPLAINT FORM FORM # 134 Complaint # American LegalNet, Inc. www.FormsWorkFlow.com HCSB PROVIDER COMPLAINT FORM #134 Page 2 of 2 PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE COMPLAINANT : THIS COMPLAINT IS BEING FILED ON BEHALF OF AN (Ple a se Check One ): EMPLOYEE.... EMPLOYER .... INSURER.... OTHER .... THE COMP LAIN ANT S NAME: CITY: STATE: ZIP CODE: AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: The following authorization for the release of medical information must b e signed by the injured employee. If this complaint is filed by an insurer or employer referencing several injured employees to demonstrate a questionable pattern of care or service by a single provider, a signed authorization for release of medical info r mation from each employee whose treatment is detailed in the complaint must be attached hereto. RELEASE OF MEDICAL INFORMATION o ard with all medical information, including but not limited to, medical records, test results, reports, and/or office notes, regarding an illness or injury for which you treated me during the period of to . I further authorize you to discuss with the Health Care Services Board any aspects of my illness or injury, or the treatment, diagnosis, or prognosis of my illness of injury. A photocopy of this authorization should be regarded as a valid r elease of the information requested. Date Signature of Employee/Patient - - Social Security No. (optional) Name of Employee/Patient (please print) Date o f Birth Address City/Town State Zip Code SEND THE COMPLETED COMPLAINT FORM, WITH ATTACHMENT(S) , AND SIGNED EMPLOYEE AUTHORIZATION(S) TO: DEPARTMENT OF INDUSTRIAL ACCIDENTS HEALTH CARE SERVICES BOARD LAFAYETTE CITY CENTER 2 AVENUE DE LAFAYETTE ATTN: Hella Dalt on A COPY OF THIS COMPLAINT AND ALL ATTACHMENTS WILL BE FORWARDED TO THE PROVIDER. Rep r oduce as Needed Revised 7 / 2019 American LegalNet, Inc. www.FormsWorkFlow.com