Complaint Reporting Form

Complaint Reporting Form
The College of Acupuncturists of Alberta investigates complaints about registered acupuncturists in Alberta. The information collected on this form, including your personal information, is collected under the authority of the Health Professions Act and will be used to process your complaint.
Your information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Email
Do you agree to receive all correspondence and documents by email?*

YesNo
What's your role in this complaint?*

I'm a patientI'm representing a patientI'm an insurance companyOther
Provide the insurance company's case or file number.
What is the patient's name?*
What is your relationship to the patient?
e.g. guardian, power of attorney, lawyer
Upload the documentation authorizing you to act on behalf of the patient.*

Cancelof

Resolution
The College has the authority to investigate concerns and discipline its members, but cannot provide financial compensation for damages. That is a matter to be addressed in civil court.
What do you hope will happen as a result of the complaint?*

EducationApologyInvestigationOther

Sign
I understand and acknowledge that:
1. The Registered Member, as named in this complaint, will be notified of my complaint and will be provided a copy of the complaint.
2. The College of Acupuncturists of Alberta may obtain the patient's/my personal health information, such as diagnostic, treatment, and patient care information, when relevant and if this matter is investigated.
3. Any information collected during an investigation will be used for the College of Acupuncturists of Alberta’s complaint process.
4. Your information may only be disclosed in accordance with the Health Professions Act and the Personal Information Protection Act or with your consent.
Date and sign the form. Your typed or electronic signature is considered as legally valid as your handwritten signature on this form.
Signature*

Clear
Date signed*

MonthDayYear
Date
Should be Empty:

Your information