Welcome to the PTBC's Online Complaint Form

The Physical Therapy Board of California is here to help Californians be careful consumers and to protect them from unscrupulous and unqualified individuals.

Read the Information Collection, Use and Access notice below.

I wish to submit a complaint about the individual named below. I understand that the Physical Therapy Board of California cannot seek restitution for damages, not provide legal advice, or assist with lawsuits. However, I am submitting this information so that it may be determined whether disciplinary action should be considered against the practitioner's license.


Business / Professional You Want To File A Complaint Against:

Fields marked with an asterisk (*) are required.

Business / Professional Name:*

Type of License:

Physical Therapist
Physical Therapist Assistant
Physical Therapy Aide
Other:

License Number:

Address (Number and Street):*

City:*

Zip Code:*

Telephone Number: () -

Person whom you dealt with:

Business / Professional E-mail Address:

Nature of Complaint:
The specific California statutes and regulations governing the practice of physical therapy are contained in the Physical Therapy Practice Act (Business and Professions Code 2600-2696, Title 16, California Code of Regulations, Division 13.2), and other pertinent sections of the Business and Professions Code.

Check the box that best describes the nature of your complaint.
Substandard Care
(e.g., Negligent Treatment, Delay in Treatment, etc.)
Unlicensed Provider or Aiding/Abetting
(Unlicensed Practice)
Sexual Misconduct/Sexual Harassment/Verbal Abuse
Unprofessional Conduct
(e.g., Breach of Confidence, Record Alteration, Fraud, Misleading Advertising, Arrest or Conviction) Office Practice
(e.g., Failure to Provide Medical Records to Patient, Patient Abandonment) Provider Impairment
(e.g., Drug, Alcohol, Mental, Physical)
Other:

Notice: Pursuant to Section 129 of the Business and Professions Code, "...Each board shall, upon receipt of any complaint respecting a licentiate thereof, notify the complainant of the initial administrative action taken on his complaint within ten days of receipt..."

Briefly describe your complaint:*

What was the date of Incident:
(mm/dd/yyyy)

What is your expected resolution regarding this complaint? (Note: Your response to this section will not alter the Board's decision):*

List all supporting documents in your possession related to your complaint, such as invoices, receipts, warranties, pictures, etc.:

Have you filed this complaint with any other agency/organization?
Yes   No

If yes, please provide the following:
Agency Name, Contact Person, Phone Number, Case Number

INFORMATION COLLECTION, ACCESS AND DISCLOSURE

Collection and Use of Personal Information. The Executive Office of the Physical Therapy Board of California maintains the information you provide on this complaint form. The information is requested pursuant to Business and Professions Code Sections 325 and 326.

Providing Personal Information Is Voluntary. If you do not wish to provide personal information, such as your name, home address, or home telephone number, you may remain anonymous. In that case, however, we may not be able to contact you or help you resolve your complaint. Omission of any required information will result in your online complaint being rejected as incomplete. This will result in the complaint not being successfully submitted to the Board.

Possible Disclosure of Personal Information. Your completed complaint form becomes the property of the Board and will be used by authorized personnel. Information concerning your complaint may be transferred to other governmental or law enforcement agencies. This may include sharing personal information you provided.

The information you provide may also be disclosed in the following circumstances:

  • In response to a Public Records Act request, as allowed by the Information Practices Act;
  • To another government agency as required by state or federal law;
  • In response to a court or administrative order, a subpoena, or a search warrant.

Contact Information. For questions about this notice or access to your records, you may contact the Physical Therapy Board of California, 2005 Evergreen Street, Suite 1350, Sacramento, CA 95815, (916) 561-8200, or email cps@dca.ca.gov. You have the right to review the records maintained on you by the Board unless the records are exempt by section 1798.40 of the Civil Code.

About You:

Enter your first name:*

Enter your last name:

Address (Number and Street):

City:

State:

Zip Code:

Daytime Telephone Number: () -

E-mail Address:

Are you the patient?
Yes   No

If no, please indicate the patient's name below:

Patient's Date of Birth: (mm/dd/yyyy)

Relationship to Patient: