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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 

FORMSDESCRIPTIONS
Complaint FormFor full description of concern or complaint.
Release of Medical Records Authorization FormFor your own medical records.
Consent for a Child FormFor medical records for your child or a child for whom you are guardian.
Holder of Power of Attorney FormFor medical records of a person who is living for whom you have Power of Attorney.
Personal Representative FormFor 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 FormFor 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.

Additional Information

If you require immediate assistance or have questions about legal issues pertaining to health care, you may contact Vermont Legal Aid, Health Care Advocacy at 1-800-917-7787 or visit the website for more information.

Vermont Legal Aid, Health Care Advocacy 

For recent Board actions taken on licensees please review our Board Actions List

Board Actions List

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Translated Complaint Forms

Complaint Form:
العربیة (Arabic) | Bosnian | ြမန်မာစာ (Burmese) | 中文 (Chinese - Simplified) | 中文 (Chinese - Traditional) | دری (Dari) | Français (French Canadian) | Kirundi | नेपाली (Nepali) | پښتو (Pashto) | Soomaali (Somali) | Español (Spanish) | Kiswahili (Swahili)| Українська (Ukrainian) | Tiếng Việt (Vietnamese) |
Release of Medical Records Authorization Form:
العربیة (Arabic) | Bosnian | ြမန်မာစာ (Burmese) | 中文 (Chinese - Simplified) | 中文 (Chinese - Traditional) | دری (Dari) | Français (French Canadian) | Kirundi | नेपाली (Nepali) | پښتو (Pashto) | Soomaali (Somali) | Español (Spanish) | Kiswahili (Swahili)| Українська (Ukrainian) | Tiếng Việt (Vietnamese) |
Consent for a Child Form:
العربیة (Arabic) | Bosnian | ြမန်မာစာ (Burmese) | 中文 (Chinese - Simplified) | 中文 (Chinese - Traditional) | دری (Dari) | Français (French Canadian) | Kirundi | नेपाली (Nepali) | پښتو (Pashto) | Soomaali (Somali) | Español (Spanish) | Kiswahili (Swahili)| Українська (Ukrainian) | Tiếng Việt (Vietnamese) |
Holder of Power of Attorney Form:
العربیة (Arabic) | Bosnian | ြမန်မာစာ (Burmese) | 中文 (Chinese - Simplified) | 中文 (Chinese - Traditional) | دری (Dari) | Français (French Canadian) | Kirundi | नेपाली (Nepali) | پښتو (Pashto) | Soomaali (Somali) | Español (Spanish) | Kiswahili (Swahili)| Українська (Ukrainian) | Tiếng Việt (Vietnamese) |
Personal Representative Form:
العربیة (Arabic) | Bosnian | ြမန်မာစာ (Burmese) | 中文 (Chinese - Simplified) | 中文 (Chinese - Traditional) | دری (Dari) | Français (French Canadian) | Kirundi | नेपाली (Nepali) | پښتو (Pashto) | Soomaali (Somali) | Español (Spanish) | Kiswahili (Swahili)| Українська (Ukrainian) | Tiếng Việt (Vietnamese) |
Executor of the Estate Form:
العربیة (Arabic) | Bosnian | ြမန်မာစာ (Burmese) | 中文 (Chinese - Simplified) | 中文 (Chinese - Traditional) | دری (Dari) | Français (French Canadian) | Kirundi | नेपाली (Nepali) | پښتو (Pashto) | Soomaali (Somali) | Español (Spanish) | Kiswahili (Swahili)| Українська (Ukrainian) | Tiếng Việt (Vietnamese) |