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Division of
Professional Regulation

Report of Healthcare Provider



INSTRUCTIONS

This form is for the use of Delaware-licensed healthcare providers and certain other entities that have a mandatory duty to report Delaware-licensed medical practitioners or other healthcare providers under Delaware law and regulations. For complete information on who must report and what must be reported, see Mandatory Reports Related to Healthcare Providers on the Division of Professional Regulation’s web site. If you need to report child abuse or neglect, see Mandatory Reports of Child Abuse or Neglect on the Division’s web site.

If you yourself are not a Delaware-licensed healthcare provider and you do not represent a healthcare institution, State agency, law enforcement, or the Medical Society of Delaware, please submit the Statement of Complaint instead of this form.

In order for the Division to start an investigation of possible violation of Delaware licensing, registration or certification laws and regulations, you must complete this online form. Be sure to submit any documents you may have to support your report by faxing them to (302) 739-2711, or email them to investigations.dpr@state.de.us. Delaware law allows the Division to keep the name of the person who files a mandatory report confidential, when appropriate.

Fields marked with ** are required by law in order to process your report

If you need help completing this form, call (302) 744-4500 and ask to speak to an investigator.



 

 

INFORMATION ABOUT PERSON FILING REPORT

A. Your Information


 


 

HEALTHCARE PROVIDER INFORMATION

B. Healthcare Provider You Are Reporting


C. Business Involved, If Any


 



 

E. Report **

Please explain in detail why you are filing this report under your mandatory duty to report. Include the date you became aware of the alleged offense(s), how you became aware of it, the nature of the offense, and the dates and locations when the offenses are alleged to have occurred. If applicable, you may fax documents in support of your report to the Investigative Unit at (302) 739-2711 or email them to investigations.dpr@state.de.us.
 


 

For more information on the investigative process or to view the laws, rules and regulations of a specific board or commission, please visit the Division of Professional Regulation’s website at dpr.delaware.gov.
 

Send Copy of Complaint to your Email Address:



 


    

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