Ibogaine Incident/Grievance Report Form
Copyright © 2004, Dora Weiner Foundation, Inc. All rights reserved.
The Ibogaine Report Form Project is being implemented to improve ibogaine therapy by providing a process for reporting information of adverse medical events, safety issues and other incidents that may impact on ibogaine treatment and care. The form enables patients and providers alike to report any incident whether negligible or life threatening. Data of a medical nature will be shared with all ibogaine providers to help assure the safety of persons treated with ibogaine. Information that is shared will not include the identity of patients or providers. An incident report may be filed by a provider, a patient or any treatment team member.
This form may also be used to file a grievance. However, grievance reports may only be filed by patients. Discussion of grievance reports will only take place between the Dora Weiner Foundation and the parties involved. Should you wish us to contact the ibogaine provider on your behalf we will require you to sign a medical information release form. Patients have the right to file a grievance report in accordance with the Ibogaine Patients' Bill of Rights.
In order to validate an incident or grievance report you will have to identity yourself and provide other contact information.
All information that you provide will be held strictly confidential in the same manner as the patient protections described in the US Federal Confidentiality Regulations 42 CFR and the Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule) as established by the Department of Health and Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, data from reports that does not identify you may be used in research or publication.
All reports must be validated. All persons submitting reports will be contacted as part of the validation process. If you do not receive a response to your report within ten business days please call us at 1 718 442-2754 or email us at the address below. If you call please indicate you are calling to discuss a Report issue.
Should you have any questions or need assistance in filling out this form, contact the Dora Weiner Foundation
When you have completed the form click on the Submit button at the bottom of the page.