Information Regarding Authorizations for Release of Information for Online Complaints
Prepare and save a copy of any supporting documents you may have in your possession pertaining to your specific complaint on your personal computer (PC); documents may include patient records, photographs, audio or video recordings, correspondence, billing statements, proof of payments, autopsy/toxicology report, police report, court documents, etc. Please note that there is a single file size limit of 10MB and a total file size limit of 50MB for attachment uploads. If you are unable to attach a file to your complaint, please send the information to complaint@mbc.ca.gov and indicate that you have filed an online complaint. Please do not file an additional complaint to submit additional information.
*Should the patient be 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 attach a copy of supportive documentation in the attachment portion of this submission for timely processing. Complete the appropriate medical releases in their entirety:
- Complete the “Authorization for Release of Information for the Subject of the Complaint” (Subject is the physician you are complaining about).
AND one of the following:
- “Physician/Provider/Facility Authorization for Release of Information” (In this form you will list all treating facilities in addition to all relevant treating providers specific to your complaint. If the incident is involving a surgical procedure, it is important that you list any pre-op or post-op providers)
OR
- “Kaiser Authorization for Release of Information” (should care and treatment have been rendered at a Kaiser facility please fill out the enclosed Kaiser form and check if it is a “northern” or “southern” facility)
Complete and save each release to your PC and attach the file to the BreEZe online complaint form by using the “Browse” button on the bottom of the Breeze Complaint Submission screen.