Public complaint form to report adverse action of licensed or unlicensed health professional, or licensed business establishment.


State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
1033 O Street, Suite 500, Lincoln, Nebraska 68508
PHONE: 402-471-0175
FAX: 402-471-6238
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Complainant - Your Information

Physical Address

Mailing Address


Complaint Filed Against

Physical Address

Mailing Address


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.

6/18/2021