Mandatory Licensed Health Professional Reporting Another Licensed Health Professional

Licensed Health Professional Reporting Alleged Violations by Another Licensed Health Professional 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

Identifying Information For Professional I am Reporting

Physical Address

Mailing Address


Reporting Party Information

Physical Address

Mailing Address


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