Nevada State Board of Medical Examiners
Complaint Investigation Division
 PO Box 7238   Reno, NV  89510
Physical Address:  1105 Terminal Way, #301   Reno, NV 89502

Phone:      In Reno: 775/688-2559
(or if calling from any other area of Nevada,
call the board's in-state toll-free number:  888/890-8210)

                                            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:                                     

Patient Name:                                                                                                                                            

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:                                                                                                                        

IMPORTANT:  PLEASE SIGN AND DATE

Signature:                                                                                                 Date:                                         

Complaint Summary