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Medi-Cal Peer Support Specialist Certification
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FAQ
Complaint Form
Peer Certification Program Complaints Form
Today's Date
(Required)
MM slash DD slash YYYY
Name of Person Filing the Complaint
(Required)
First
Last
How Can We Reach You?
We may need to contact you for further information. Please enter your contact details.
Phone Number
(Required)
Please enter the phone number of the person filing the complaint.
Email
(Required)
Enter the email address of the person filing the complaint.
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Preferred Method of Contact
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Please select the best way to contact you if needed.
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Email
Phone
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
(Required)
For ethical violation complaints, report must be within 3 years of violation.
MM slash DD slash YYYY
Complaint Type
(Required)
Please select complaint type…
Certified Medical Peer Support Specialist (CMPSS)
CalMHSA Approved Training Provider
General Complaint
Please select complaint type below. For more than one complaint type, please file separately.
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
(Required)
Please describe the complaint as detailed as possible including any details that are pertinent to the investigation.
Supporting Document
Max. file size: 2 MB.
Please feel free to upload a supporting document. File should be less than 2MB.
Name
This field is for validation purposes and should be left unchanged.