The complaint shall set forth the name and address of the complainant, his professional qualifications, the name and address of the hospital whose governing body is alleged to have committed the unlawful discriminatory practice complained of, the staff membership or the professional privileges sought by the complainant, a statement in detail of the alleged unlawful discriminatory practice, and the medical group practice or nonprofit health insurance plan participated in by the complainant.
N.Y. Comp. Codes R. & Regs. Tit. 10 § 95.2