Physical Therapy Board of California

Submit Complaint by Mail

---

You can call the Consumer Protection Services Program (CPS) to request a paper copy of our complaint form, or you can fill out the following form:

Consumer Complaint Form

A complainant may be asked to sign an Authorization for Release of Patient Health Information form if PTBC needs to obtain medical records or information from a provider, hospital, or other sources to investigate a complaint. If the complaint is NOT within the Board's jurisdiction, PTBC may refer you to the appropriate agency or organization.

Complete:
Authorization for Release of Patient Health Information for the Subject of the complaint (Subject is the provider you are complaining about.)

Complete the following medical release forms in their entirety, if applicable:

Other Provider/Facility Authorization for Release of Patient Health Information
(In this form you will list all providers you received treatment from in addition to the Subject of your complaint.)

-OR-

Kaiser Authorization for Release of Patient Health Information
(If you received care/treatment at a Kaiser facility, complete this form and indicate whether it’s a “Northern” or “Southern” California Kaiser facility)

*** If the patient is deceased, the person signing the release form(s) must be a legal representative as demonstrated on a durable power of attorney, death certificate, or an executor of will/estate document. (Please enclose copy of supportive documentation).

Note: Except for the name of the physical therapist/physical therapist assistant, all information requested is voluntary, but failure to provide the requested information may delay or prevent the investigation of your complaint. The information on the complaint form will be used in part to determine whether a violation of state law or regulation has occurred. If a violation is substantiated, the information may be transmitted to other government agencies, including the Attorney General's Office.

Complaints should be mailed to: