BCPA-Certificant-Complaint-Form - Patient Advocate Certification Board Organization

BCPA-Certificant-Complaint-Form

Complaint Form

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date Submitted

Relationship with the person against whom the complaint is being filed.

Name of the Certificant against whom the complaint is being filed.

Please state the facts which make you believe that the individual you have named has committed a violation of BCPA Standards.

Please list any other persons with knowledge of the violation. PACB reserves the right to contact any witnesses listed below.

Please list any other organizations and/or agencies with whom you have filed a formal complaint about this alleged violation of BCPA Standards.

Note: By submitting this form, you acknowledge that you understand that all information, including a copy of this complaint will be provided to the PACB Compliance committee and the certificant. You further attest that the facts and allegations in this complaint are true and correct to the best of your knowledge and belief.

I understand