Fillable Printable Psychology Complaint E Form

Psychology Complaint E Form

Kentucky State Board of Psychology

PO Box 1360

Frankfort KY 40602

Telephone: (502) 564-3296 FAX: (502) 564-4818

Filing a Complaint

What are your rights?

You have a right to expect a professional standard of care and conduct from a psychologist. If you believe a

psychologist has violated Kentucky statutes or regulations, you may send a written complaint to the Kentucky State Board of

Psychology. As the body responsible for regulating the psychological profession and protecting the public in matters related to

psychology, the Board will review your complaint and take appropriate action.

How does the complaint proces s work?

Complaints that have been received in writing at the Board office will be acknowledged immediately by letter. A copy

of your complaint will be sent to the psychologist for a response. The complaint and response will then be reviewed by the

Board members at a subsequent meeting. If no law appears to have been violated, you will receive notification from the

Board. If the Board believes a law may have been violated, an investigation will take place. If the Board files formal charges

against a psychologist as a result of the investigation, an administrative hearing may be held. This formal hearing involves

lawyers, a court reporter, a hearing officer and witnesses. If the Board finds that the psychologist has not met the prescribed

standard of care and conduct, it has the authority to impose penalties ranging from a reprimand to a suspension or loss of a

license. A penalty may be reached by agreement between the Board and the psychologist.

What might I expect from filing a complaint?

The complaint process is a detailed and careful one, and you should expect some delay. In every case the

psychologist will be informed that a complaint has been filed, provided with a copy of the complaint, the name of the

complainant, and the disposition of the complaint. Not every complaint results in disciplinary action by the Board if the

psychologist has not violated the laws governing the psychological profession. If charges are filed, a hearing may be held

similar to a court trial, and it is open to the public. You may be subpoenaed as a witness to provide testimony regarding the

case. In this event the Assistant Attorney General assigned to the Board will assist you in preparing for the hearing. If the

Board orders a specific sanction, the psychologist has the right to appeal the decision to a court of law thereby resulting in a

delay in the decision becoming final. While you may have an opinion regarding the process and outcome of processing your

complaint, please remember that the decisions to dismiss or settle a case or propose disciplinary measures are solely the

decision of the Board and may be subj ect to review by the courts.

If the Board files formal charges or takes formal action against a psychologist, most portions of the investigative file

will become “public reco rd” which can be viewed by any individual who requests, in writing to do so. The record may include

your written complaint, transcripts, or reports of interviews, letters, and other re ports. All testimony and evidence admitted in

a formal hearing have the status of public reco rd as well. Patient records obtained in the process of investigation usuall y can

be protected from disclosure as public records.

Throughout the various stages of the complaint process, you will be kept informed. You will also be advised of the

final outcome.

How do I make a complaint?

You should complete the complaint form that accompanie s this information sheet. Make sure you give all pertinent

information. Please sign the com plaint form so that the Board may look further into your concerns. If your complaint refers to

treatment of a specific patient, the patient must sign the “Client Agreement to Release Information” form a s well. Complaints

and release forms sh ould be mailed to:

KENTUCKY BOARD OF PSYCHOLOGY

PO BOX 1360

FRANKFORT, KY 40601

Complaint No: Date Received:

KENTUCKY BOARD OF PSYCHOLOGY

Complaint Form

Person Filing Complaint

Name:

Address:City:State:ZipCode:

DayTelephone:( )-EveningPhone:( )-

Patient Information

(If Applicable)

Name:

Address:City:State:ZipCode:

DayTelephone:( )-EveningPhone:( )-

Relationship to person filing complaint:

Name of Psychologist

Name:

Address:City:State:ZipCode:

Day Telephone:

( )-

Name and phone number of persons who may provide additional information

1. Name: Telephone: ( ) - Type of Information:

2. Name: Telephone: ( ) - Type of Information:

3. Name: Telephone: ( ) - Type of Information:

4. Name: Telephone: ( ) - Type of Information:

Brief Summary of Complaint

(Please be specific as possible reg arding names, dates, locations, and action which you believe to be improper, unethical or

unprofessional. Please attach copies of any documents or records pertinent to your complaint.)

By signing this complaint form, I hereby certify that the information is complete and true to the best of my knowledge.

Signature: ____________________________________ Date: ______________________________

If your complaint concerns your treatment by the psychologist, please sign and enclose the “Client Agreement to Release

Information” form.

*********************************************************************************************************************

Send to: KENTUCKY BOARD OF PSYCHOLOGY Phone: (502)564-3296

PO BOX 1360 Fax: (502)564-4818

FRANKFORT, KY 40601

Authorization for Release of Medical and Psychological

Records to the Kentucky Board of Examiners of Psychology

I,, the undersigned,

print name here

do hereby authorize the full release of any and all medical and psychological

records, correspondence, billing information, and medical and psychological

reports and evaluations from ____________________________________

Licensed/Certified Psychologist, regarding the medical and psychological

history, diagnosis, assessment, evaluation, and/or treatment of me to the

Kentucky Board of Examiners of Psychology or any authorized agent or

investigator of the Board.

I understand that the above records may be used by the Board in the

investigation and possible disciplinary prosecution under KRS Chapter 319

against the psychologist. I further understand that the Board will make

reasonable efforts to protect the confidentiality of my records under KRS Chapter

61 and Chapter KRS 13B, or other applicable law. This involves health oversight

activities and administrative proceedings of the Board. As such, this disclosure

is permitted under 45 C.F.R. Section 164.512(a), (d), and (e), the regulations

implementing the Health Insurance Portability Accountability Act (HIPAA).

A photocopy of this authorization shall be deemed effective as an original.

This authorization shall be effective for one year from the date of signing

unless retracted in writing by the undersigned.

___________________________________

Date Signature of person, or parent/legal guardian if

person is under 18 years of age