Mandatory Report from a Licensed Facility/Organization Reporting a Licensed Health Professional

Licensed Health Facilities Reporting Licensed Health Professionals for adverse action to the Division of Public Health – Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

We are a*:

Identifying Information For Professional I am Reporting

Physical Address

Mailing Address

List the profession and license number for each Nebraska license, certificate, or registration held.

Profession
License Number

Reporting Party Information

Physical Address

Mailing Address




Date action was taken:
Effective Date:
Duration of the effect of the action:
Type of adverse action:

Name:
Date of Birth:
Address:
Date of act, omission, or conduct:
Where did it occur?

Name of patient or client:
Address:
Name of court:
Address:
Date of judgment, settlement, or award:
Date of payment:
Amount of payment:

Name:
Title:
Address:
Phone:
Name:
Title:
Address:
Phone:
Name:
Title:
Address:
Phone:

Reason for Complaint

Please describe the complaint and include as much detail as possible. Include where and when the complaint occurred and whom the complaint is against.
Allowed file extensions: .tiff, .tif, .pdf, .doc, .docx, .jpg, .jpeg, .png and .gif
Max file size allowed: 20 MB.

The statements I have made are true and correct to the best of my knowledge. By signing this form, I am agreeing to the submission of this complaint by electronic means. I understand that an electronic signature has the same legal effect and enforceability as a written signature on a complaint.

10/7/2024