Complete all the fields so that your complaint is considered as validly submitted.


Your complaint shall be reviewed by and administrator and you shall receive a response from the Agency.

 

First name*
Middle name*
Family name*
Claimants address*
Phone*
-mail*
Medical treatment facility/provider, object of the complaint*
Description*
Attach a document


(in .jpg, .tiff, .pdf form, up to 5))

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