Licensing Enforcement and HPU Complaint Form

A copy of this complaint form will be submitted to the individual/business listed below in Section 2. The Office of the Indiana Attorney General cannot accept complaints from anonymous complainants. If you wish to remain anonymous, please contact the Indiana Professional Licensing Agency. Please note that not providing your name or other identifiable information can limit the ability to thoroughly investigate consumer complaints.

= Required Information

Section 1: Your Information

Are you with an agency or organization and filing on behalf of another individual?	(loading...)

Salutation
First Name
Middle Name
LastName
Suffix
Address
City
State
ZipCode

Age

Phone (area code required)

Best way to contact you

Electronic Mail

Mail

Telephone

Are you or your spouse active duty military?

Is your complaint regarding a healthcare or mental health practitioner?

If yes, please provide the patient’s name (if different that you) and patient’s date of birth. Otherwise, enter 'N/A'

If your complaint is regarding a veterinarian or veterinary office, please provide the name and type of animal:

2. Who is your complaint against?

Individual
Business/Facility (if applicable)
Title/Role
Address
City
State

Zip

Phone (area code required)

Website (if applicable)

Social Media Account Names (if applicable)

Does the individual/facility possess an Indiana professional or healthcare license?

Yes

If yes, please provide the license number of the individual/facility (if known):

3. What type of profession is the complaint against? (Please select all that apply)

Professional Licensing

Selections

Add

Remove

Selected

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Healthcare Licensing

Selections

Add

Remove

Selected

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4. Transaction/Incident Details

Date of Transaction/Incident

Location of Transaction/Incident

Nature of Transaction/Incident

Selections

Add

Remove

Selected

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Description of Incident

Documents available from the transaction/incident (any documents related to the incident should be submitted with this complaint form)

Healthcare Records

Mental Health Records

Veterinarian Records

Real Estate Documentation (i.e. Disclosure Form, Closing Documents, Lease)

Criminal or Civil Court Records

Written Agreement/Contract

Invoices

Inspection Report

Other

Are you represented by counsel?

Yes. If yes, please list name and contact information of attorney

Have you filed a complaint with any other agency? If yes, please provide a copy of that complaint.

Yes. If yes, what agency:

5. Consent and Verification

Do you consent to disclosing the following information to the public?

The nature of the complaint and the individual/business name

Yes

Your name

Yes

Your phone number

Yes

I affirm, under the penalties for perjury, that the foregoing representations are true. I consent to the Consumer Protection Division obtaining or releasing any information in furtherance of the disposition of this complaint. I consent to the release of information included in this complaint to other public agencies attempting to discover ongoing fraudulent patterns or practices and for the purpose of law enforcement. I understand that I should not include my Social Security Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).

Your Name

Date

[ 4/7/2025 ]

6. Consent to correspondence by Email

Do you consent to the Consumer Protection Division sending youcorrespondence related to this complaint to your email address? If yes, you will not bemailed such correspondence via the U.S. Postal Service. If you select Yes please enterthe email address we should use to send correspondence even if it is the same as theemail address you entered earlier.
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If you have supporting documentation or materials related to this complaint that you would like to upload at this time, please check the box below. After you click the Submit button below you will be directed to another page where you can upload those files.

Sun	Mon	Tue	Wed	Thu	Fri	Sat

Acupuncture
Anesthesiologist Assistant
Athletic Trainers
Behavior Analyst
Behavioral Health and Human Services
Chiropractors
Dentistry
Diabetes Educators
Dietitians
Genetic Counselors
Health Facility Administrators
Hearing Aid Dealers
Home Healthcare Equipment
Midwives
Nurses
Occupational Therapists
Optometrists
Pharmacy
Physical Therapists
Physicians
Physician Assistants
Podiatric Medicine
Psychology
Speech Language Pathology and Audiology
Veterinary Medicine