Online Notification (Complaint) Form

If you are a health practitioner, employer or education provider making a mandatory notification regarding the notifiable conduct of a registered practitioner (including student), please DO NOT fill out this form. You need to contact the Australian Health Practitioner Regulation Agency (AHPRA) on 1300 419 495 or www.ahpra.gov.au

Your Details
Patient Details
I am lodging this notification (complaint) on behalf of:*required
Has this person agreed to you making this notification (complaint) on their behalf?*required
Is this person deceased?*required
Please provide the relevant contact details below for the person who received the service
Notification (Complaint) Details
Have you spoken with anyone from the HPCA prior to lodging this notification (complaint)?

The HPCA will provide specific details of the notification (complaint) to the health practitioner or student to seek a response from him/her



Have you approached the health practitioner or student about this notification (complaint)?*required
Have you spoken to anyone else about this notification (complaint)?
Is there any additional information you wish to provide?
It may be necessary for the HPCA to access your personal health records (or those of the person who was provided with the service) in handling this notification (complaint), is this ok? *required
A copy of your notification (complaint) will be provided to the practitioner or student, to ask them to provide a response. Please indicate your acceptance of this by ticking Yes or No:*required
Notification (Complaint) Details

Please be aware that the HPCA has a legal responsibility to deal with all notifications (complaints) promptly. By submitting this form, you give consent for the HPCA to contact you and to make any inquiries the HPCA thinks appropriate to assess the notification (complaint).

Under section 145A(1) of the Health Practitioner Regulation National Law (NSW) and the Health Care Complaints Act 1993, the HPCA and the Health Care Complaints Commission are required to consult with each other on the appropriate course of action for all notifications (complaints) received.

Mandatory field(s) marked with *