MARYLAND BOARD OF PHARMACY COMPLAINT FORM and

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MARYLAND BOARD OF PHARMACY

COMPLAINT FORM and INFORMATION

Dear Customer:

Attached is the complaint form used by the Board of Pharmacy to review and respond to

consumer complaints. Please complete the form and return it to the address below:

Maryland Board of Pharmacy

Deena Speights-Napata

4201 Patterson Avenue

Baltimore, Maryland 21215

Or you may send the form as an email attachment to:

deena.speights[email protected]

As a reminder, complaints concerning the prices of prescriptions should be referred to the

Consumer Protection Division, the Office of the Attorney General, located at 200 Saint

Paul Place, 16

th

Floor, Baltimore, Maryland 21202,

telephone number 410-528-8662.

You may also file a complaint online. Their web site is:

http://www.oag.state.md.us/consumer/index.htm.

We look forward to assisting you with your complaint.

Other important telephone numbers for complaints and consumer protection:

Medicaid Fraud

410-576-6521

Consumer Protection Agency

410-528-8662

Maryland Poison Center

800-222-1222

Pharmacy Assistance Program

800-492-5231

Physicians Board

410-764-4777

Nursing Board

410-585-1900

Dental Board

410-402-8500

Maryland Better Business Bureau

410-347-3990

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Department of Health

Maryland Board of Pharmacy

4201 Patterson Avenue

Baltimore, MD 21215-2299

410-764-4755

COMPLAINT FORM

A. The Board is charged with investigating complaints against any person or firm engaged in

the distribution of prescription drugs in Maryland.

B. If your complaint concerns the provision of pharmacy services by someone who you

believe is not duly licensed, this information should also be forwarded to the Board.

C. Please note that the Board does not have authority to handle or resolve complaints

concerning billing, pricing, coverage, reimbursement and similar purely economic matters

where the facts do not appear to support a claim of fraud or misrepresentation. However,

we do refer such complaints to the Health Education and Advocacy Unit in the Consumer

Protection Division of the Attorney General’s Office. You will be notified if the Board

makes this referral.

D. Your complaint must be submitted in writing. If you are handicapped and cannot write

your complaint, you may make an appointment to give your complaint in person.

E. Please be as accurate and as complete as possible.

F. Please allow time for the Board to complete its investigation. All complaints will be

carefully reviewed.

1. Name of Complainant: _____________________________________________

a. Address: ______________________________________________________

a. Home telephone #: _______________________________________________

b. Business telephone #: _____________________________________________

c. Email address: ___________________________________________________

2. Name of person preparing this complaint if it differs from above (#1):

_________________________________________________________________

a. Address: _________________________________________________________

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b. Home Telephone #: ________________________________________________

c. Business Telephone #: ______________________________________________

3. Name of the pharmacist(s) involved in the complaint:

_________________________________________________________________

a. Name of pharmacy involved in the complaint:

_________________________________________________________________

b. Address of the pharmacy involved in the complaint:

_________________________________________________________________

4. If your complaint is against a distributor of drugs, please give the following:

a. Name of the firm: __________________________________________________

b. Address: _________________________________________________________

_________________________________________________________________

5. If you have made a complaint to any other government agency, professional

association, etc. about this matter, please indicate their names and addresses below:

__________________________________________________________________

6. If your complaint involves a prescription drug, please write down all of the information

appearing on prescription label or enclose a CLEAR photocopy of the label:

__________________________________________________________________

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__________________________________________________________________

7. Date incident occurred: ____________________________________________

8. In your own words, clearly state the exact nature of your complaint, including as much

detail as necessary to accurately describe the situation. You may use additional pages if

needed; please number the pages and sign each sheet at the bottom.

__________________________________________________________________

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__________________________________________________________________

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9. Have you discussed your complaint with the pharmacist(s) of firm who is named in the

complaint? YES _____ NO _____

10. State the name(s), address(es), and telephone number(s) of any person(s) who witnessed

the incident or may otherwise possess additional information about your complaint.

__________________________________________________________________

11. State the name of the physician or other authorized prescriber who provided the

prescription for the medication involved in your complaint:

a. Prescriber’s name: _________________________________________________

b. Prescriber’s address: _______________________________________________

_________________________________________________________________

c. Prescriber’s telephone #: _____________________________________________

12. I HEREBY DECLARE AND AFFIRM UNDER PENALTY OF PERJURY THAT

THE MATTERS SET FORTH IN THE FOREGOING COMPLAINT ARE TRUE

AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION,

AND BELIEF.

Signature of Complainant:

______________________________________________________ Date: ____________________

Signature of person preparing the complaint, if not the person above:

______________________________________________________ Date: ____________________

Revised 9/4/2018, 2/25/2020