MARYLAND BOARD OF PHARMACY

COMPLAINT FORM and INFORMATION

 

 

Dear Consumer:

 

Attached is the complaint form used by the Board of Pharmacy to recognize and act upon consumer complaints.  Please complete the form and return it to the address below.

 

Maryland Board of Pharmacy

4201 Patterson Avenue

Baltimore, Maryland 21215

 

You may fax the form to the Board at (410) 358-6207

 

Or you may send the form as an email attachment to: MDBOP@DHMH.STATE.MD.US

 

 

As a reminder, complaints concerning the prices of prescriptions should be referred to the Consumer Protection Division of the Office of Attorney General located at 200 Saint Paul Place, 16th Floor, Baltimore, Maryland  21202.  You may also file a complaint online, their web site is:  http://www.oag.state.md.us/consumer/index.htm.

 

We look forward to assisting you with your complaint and will keep you updated as to its status.

 

 

Other important telephone numbers for complaints and consumer protection:

 

Medicaid Fraud                                    410-576-6521

Consumer Protection Agency                410-576-6550

Maryland Poison Center                       800-222-1222

Pharmacy Assistance Program  410-767-5398

Physicians Board                                  410-764-4777

Nursing Board                                      410-585-1900                      

Dental Board                                        410-402-8500

Maryland Better Business Bureau          410-347-3990

 

 

 

 

 

 

 

 

Department of Health and Mental Hygiene

Maryland Board of Pharmacy

4201 Patterson Avenue

Baltimore, MD  21215-2299

410-764-4755

 

 

COMPLAINT FORM

 

 

A.             The Board is charged with investigating complaints against any person or firm

     engaged in the packaging, or distribution of prescription drugs

      in Maryland.

 

B.              If your complaint concerns the provision of pharmacy services by someone

   who you believe is not duly licensed, this information should also be      

   forwarded to the Board.

 

C.                             Please note that the Board does not have authority to handle or resolve complaints concerning billing, pricing, coverage, reimbursement and similar purely economic matters where the facts do not appear to support a claim of fraud or misrepresentation.  However, we refer such complaints to the Health Education and Advocacy Unit in the Consumer Protection Division of the Attorney General’s Office.  You will be notified if the Board makes this referral.

 

D.                            Your complaint must be submitted in writing.  If you are handicapped and cannot write your complaint, make an appointment to give your complaint in person. 

 

E.                             Please be as accurate and as complete as possible.

 

F.                             Please allow time for the Board to complete its investigation.  All complaints will be acted upon.

 

1.   Name of Complainant:

                       

a. Address:

           

 


                        b. Home telephone #:

 

                        c. Business telephone #:

 

  2.  Name of person preparing this complaint if it differs from above (#1):

 

 

 


a. Address:

                         

                       

                        b. Home telephone #:

 

                        c. Business telephone #:

 

                3.     Name of pharmacist(s) named in complaint:       

 

                   

 


                                 

 


a.      Name of pharmacy involved in complaint:

 

b.      Address of pharmacy involved in complaint:

 

 

 

 


4.      If your complaint is against a distributor of drugs, please give:

 

a. Name of the firm:

 

            b. Address:                 

 

 


                       

5.      If you have made a complaint to any other government agency, professional association, etc. about this matter, please indicate their names and addresses below:

 

 

 

 

 

 

 

 


6.      If your complaint involves a prescription drug, please write down all of the information appearing on prescription label or enclose a CLEAR photocopy of the label:

 

 


             

 

 

 

 

 

 

 


                7.    Date incident occurred:

 

                8.     In your own words, state in as much detail as possible the exact nature of your

complaint.  Use as many additional sheets of paper as necessary, number the

pages and sign each sheet at the bottom.

 

 

 

 

 

 


                       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


9.          Have you discussed your complaint with the pharmacists or firm about whom

you are complaining:    Yes                  No

 


10.       State the names, address and telephone numbers of all persons who witnessed

or may have any additional information about your complaint.

 

 

 

 

 

 


 

 


11.       State the name of the physician or other authorized prescriber who provided the

        prescription for the medication involved in your complaint:

 

        a. Prescriber’s Name:

 

  b. Prescriber’s Address:

 

 


  c. Prescriber’s telephone number:

 

12.       Do you consent to the release to this Board and its investigation of any medical

records relating to you and this incident from any hospital or related institution

or physician?   Yes                               No

 

 

13.       I HEREBY DELARE AND AFFIRM UNDER PENALTIES OF PERJURY

THAT THE MATTERS SET FORTH IN THE FOREGOING COMPLAINT IS TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.

 

 

 

 

 

 

 

Signature of Complainant:                                                          Date:

 

 

 


Signature of person preparing complaint, if not the person above:

 

 

                                                                                                         Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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(Revised 11/26/01)