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Medi-Cal Peer Support Specialist Certification
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File A Complaint
Peer Certification Program Complaint Form
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Today's Date
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Name of Person Filing the Complaint
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Phone Number
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Please enter the phone number of the person filing the complaint.
Email Address
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Email Address
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Complaint Details
Please fill out the information below with as much details as possible. You can upload any supporting documents or files below.
Event Date
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For ethical violation complaints, report must be within 3 years of violation.
Complaint Type
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Please select complaint type below. For more than one complaint type, please file separately.
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Certified Medical Peer Support Specialist (CMPSS)
CalMHSA Approved Training Provider
General Complaint
Who is the complaint against?
Please provide the name of the Training Provider or Certified Peer Support Specialist (CMPSS) you are filing a complaint against. For general complaints, you may leave blank.
Details of Complaint
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Please describe the complaint as detailed as possible including any details that are pertinent to the investigation.
Supporting Documents
Optional: You may upload any files as supporting documents for this complaint.
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Max. file size: 2 MB, Max. files: 4.
Email
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