Midwifery Complaint Form

Licensed Lay Midwifery Complaint Form

Name of Midwife Being Reported(Required)
Address of Midwife Being Reported
Name of Person Filing Complaint(Required)
Address of Person Filing Complaint

Witness Information

Witness #1 Name
Witness #1 Address
Witness #2 Name
Witness #2 Address

Please answer each question below

Did the midwife provide prenatal care to a client(s) in Arkansas?(Required)
Did the midwife provide labor/delivery services outside of a hospital in Arkansas?(Required)
Did the midwife accept payment for any services provided?(Required)

Description of Complaint

Describe in detail what the midwife has done or failed to do that may violate the Rules and Regulations Governing the Practice of Licensed Lay Midwifery in Arkansas. Include who, what, when and where. Client names may be given in a complaint to a Licensing Agency without violating the client’s confidentiality or HIPAA Rules. If reporting a conviction, give the name of the court, e.g., Municipal Court of ___, Circuit Court of ___, Federal Court of ___.

Severe Weather: Donate to the Arkansas Disaster Relief Program

The Arkansas Disaster Relief Program is available to assist those impacted by disasters across the state of Arkansas. Under the Arkansas Disaster Relief Program, the Arkansas Division of Emergency Management (ADEM) is able to provide funds for immediate needs for disaster relief to communities experiencing major impacts from a DECLARED disaster. These funds are to be utilized as additional state and federal program availability are being determined.