File a Complaint

12/21/2024 9:52:25 PM

Please do not use the back button of your browser while you are in the form. If at any time you wish to exit the form, please click the "Exit" button located at the bottom of the page.

Complainant's Information

Please provide your personal information below.


First Name:	Middle Initial:	Last Name:
Address:
City:	State:	Zip:
Daytime Phone Number:	Evening Phone Number:	Email:

Patient Information

Please provide the name(s) and date(s) of birth of patient(s) relative to this complaint.


Patient Name:	Patient Date of Birth:	Relationship to Patient:
Click the "Add" button below to provide additional patient information.

Prescription Information

Please provide the information on the prescription label relative to your complaint.


Prescription Number:	Name of Medication:	Date of Medication Filling/Dispensing:

Complaint Information


What was the date of the incident in question?
Is your complaint against a business such as a pharmacy, hospital, wholesale distributor or mail order pharmacy?	Yes	No


Name of Business:	Type of Business:	Phone Number:
Address:
City:	State:	ZIP Code:


Is your complaint against a person, such as a pharmacist, pharmacy technician or cashier?	Yes	No


Name of Individual:	Individual's Role (pharmacist, pharmacy technician, etc.):
Please explain/describe your complaint in detail:
Please list the remedy that you are seeking:
Please upload copies of documents/exhibits that support your complaint (medication guidelines, photos, letters, receipts, etc.) Click here for recommendations on uploading files.

It is the duty of the West Virginia Board of Pharmacy ("Board") to protect the public health, safety, and welfare by the effective regulation of the practice of pharmacy; the licensure of pharmacists; and the licensure and regulation of all sites or persons who distribute, manufacture, or sell drugs or devices used in the dispensing and administration of drugs or devices within the State of West Virginia. The Board may discipline any licensee for violations of the law or applicable Legislative Rules. The Board has no jurisdiction over business disputes, billing disputes, insurance coverage, personality conflicts, scheduling issues, or employee/employer disputes.

To ensure procedural due process, a copy of this Complaint Form will be provided to the individual or entity against whom the complaint is filed. Further, once completed, this Complaint Form is a matter of public record. Please note that action taken on this complaint may result in a hearing which may require your attendance to testify regarding the issues involved.