The Vermont Board of Medical Practice investigates complaints of unprofessional conduct, and may issue reprimands; or revoke, suspend, or place conditions on professional licenses and certifications, or take action where appropriate to protect public health and safety.
If you have a concern about a medical professional licensed by the Board, complete and email or mail the appropriate forms from the list below. We encourage electronic submission of these forms by sending them to the email address below.
Forms are provided in a fillable PDF format. Digital signatures are acceptable when completing these documents. To access the digital signature portion of the fillable format, you must download and complete the form in Adobe. Free versions of Adobe can be found at Download Adobe Acrobat Reader: Free PDF viewer. Instructions to setup an Adobe digital signature can be found here.
- NOTE - To investigate a claim, the Board must receive the Complaint form and Authorization for Release of Medical Records form. Scroll down for forms.
- If you have questions, email [email protected] or call (802) 657-4220.
Email Address: [email protected]
Mail Address: Vermont Board of Medical Practice, 280 State Drive, Waterbury, VT 05671-8320
Complaint Forms
| FORMS | DESCRIPTIONS |
|---|---|
| Complaint Form | For full description of concern or complaint. |
| Release of Medical Records Authorization Form | For your own medical records. |
| Consent for a Child Form | For medical records for your child or a child for whom you are guardian. |
| Holder of Power of Attorney Form | For medical records of a person who is living for whom you have Power of Attorney. |
| Personal Representative Form | For medical records of a person who is deceased / you were able to participate in health care and had a Power of Attorney, were named in an Advanced Directive, or as a guardian or conservator. |
| Executor of the Estate Form | For the medical records of a patient who is now deceased, and you are the Executor of the Estate. This title varies among states, and may also be personal representative, administrator, trustee, etc. depending upon the location of the estate. |