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 firstname.lastname@example.org. 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.