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You are important to us and we want to be able to communicate better & faster. Please click here to enter your email address for our records
You are important to us and we want to be able to  communicate better & faster!

Please click here to enter your email address for our records!

Last Updated: 03/25/09 08:13:41 AM

Complaint Form

NOTE:

Please print out this Complaint Form on your computer printer. On the printed Complaint Form, please type or neatly print your complaint information and summary. Be as concise as possible. Make copies of any documents you have which support your allegation(s) and attach them to your completed Complaint Form. Please mail your completed Complaint Form and attachments to the above address.
Your Name:
Phone Number:
Address:
City:
State:
Zip:
E-mail:
 
Patient Date of Birth:
Patient Social Security Number:
 
Physician(s), PHysician Assistant(s), Practitioner(s) of Respiratory Care named in complaint:
1. Physician, Physician Assistant, Practitioner of Respiratory Care Name:
 
  Address:
  City:
  State:
  Zip:
  Phone Number(s):
  
2. Physician, Physician Assistant, Practitioner of Respiratory Care Name:
   
  Address:
  City:
  State:
  Zip:
  Phone Number(s):
  
3. Physician, Physician Assistant, Practitioner of Respiratory Care Name:
   
  Address:
  City:
  State:
  Zip:
  Phone Number(s):
  
Date(s) of Occurrence:
Treatment Received At: (please mark the following that apply, including name and address)
Physician's Office:
Hospital:
Other:
  
Did you obtain a second opinion from another physician?
               Yes         No
If "Yes": Name of Physician:
  Physician Address:
  Diagnosis:
  
Complaint Summary:
   

 

 

Phone:  (775) 688-2559 
Fax: (775) 688-2321
from any other area of Nevada, call toll-free:
(888) 890-8210
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Mailing Address: P.O. Box 7238, Reno, NV 89510
Board of Medical Examiners
E-mail:nsbme@medboard.nv.gov

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