Midwifery Complaint Form

Licensed Lay Midwifery Complaint Form

Name of Midwife Being Reported(Required)

First Last

Address of Midwife Being Reported

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Person Filing Complaint(Required)

First Last

Email of Person Filing Complaint(Required)

Address of Person Filing Complaint

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to Midwife(Required)

Witness Information

Witness #1 Name

First Last

Witness #1 Phone Number

Witness #1 Email

Witness #1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Witness #2 Name

First Last

Witness #2 Phone Number

Witness #2 Email

Witness #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please answer each question below

Did the midwife provide prenatal care to a client(s) in Arkansas?(Required)

Yes

Unknown

Did the midwife provide labor/delivery services outside of a hospital in Arkansas?(Required)

Yes

Unknown

Did the midwife accept payment for any services provided?(Required)

Yes

Unknown

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 ___.

Describe the complaint

Programs & Services

Licensed Lay Midwifery Complaint Form

Witness Information

Please answer each question below

Description of Complaint

Helpful Links

Contact ADH

Your Arkansas.gov

Top Online Services

Helpful Information

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