Medi-Cal Peer Support Specialist Certification

Peer Certification Program Complaints Form

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Name of Person Filing the Complaint(Required)

How Can We Reach You?

We may need to contact you for further information. Please enter your contact details.
Please enter the phone number of the person filing the complaint.
Email(Required)
Enter the email address of the person filing the complaint.
Please select the best way to contact you if needed.

Complaint Details

Please fill out the information below with as much details as possible. You can upload any supporting documents or files below.
For ethical violation complaints, report must be within 3 years of violation.
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Please select complaint type below. For more than one complaint type, please file separately.
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.
Please describe the complaint as detailed as possible including any details that are pertinent to the investigation.
Max. file size: 2 MB.
Please feel free to upload a supporting document. File should be less than 2MB.
This field is for validation purposes and should be left unchanged.