New Jersey State Board of Medical Examiners Online Complaint Form

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New Jersey State Board of Medical Examiners
Online Complaint Form

Please be advised that this complaint form, along with any supporting documents that you provide to us, will be handled confidentially throughout the time that the Board investigates the allegations you have made. The document(s) will thereafter continue to be considered "confidential" if the Board concludes that there is no cause for action against the physician about whom you have complained. If the Attorney General determines that an enforcement action should be initiated, the document(s) you have supplied may be needed as evidence, and you may need to testify.

If a disciplinary action is taken against the physician about whom you have complained, based in part or in whole upon your complaint, then your complaint will be considered to be a "government record" and may be disclosed in response to a request made pursuant to the Open Public Records Act ("OPRA"). However, records relating to an individual's medical, psychiatric or psychological history, diagnosis, treatment or evaluation are not "government records" subject to public access pursuant to OPRA, and accordingly, references to your name and other identifying information may be removed, if deemed necessary, from any documents produced pursuant to an OPRA request.

If you would rather mail in your form you can download it by clicking here.

Consumer Information:

Last Name : First Name :
(Your name will be used as your case identifier/tracker.)

Street Address :

City : , State : ZIP Code :

Telephone Number(s) : Home : Work :

E-Mail Address :

Complaint Reported Against:

Name: Title:

Business Name:

Address:

City: State: ZIP Code:

Telephone Number:

Dates of Treatment/Service: from to

1. What is the relationship between the complainant and the consumer or patient?
If other, please specify:

2. Please provide the following information about the consumer or patient if he or she is someone other than the complainant.

Name: Date of Birth:

Street Address:

City: , State: ZIP Code:

Telephone Number(s): Home: Work:

3. Please provide the following information about any other practitioner or licensee involved in the matter about which you are filing a complaint.

(a) Name: Title:

Street Address:

City: State: ZIP Code:

Home Telephone Number: License number:

(b) Name: Title:

Street Address:

City: , State: ZIP Code:

Telephone Number: License number:

4. Please provide the following about anyone who was a witness to the matter about which you are filing a complaint.

(a) Name:

Street Address:

City: , State: ZIP Code:

Telephone Number(s): Home: Work:

(b) Secondary Name :

Street Address:

City: , State: ZIP Code:

Telephone Number(s): Home: Work:

5. What is the nature of the complaint?

Briefly explain the problem if it is not listed above:

6. Please describe the facts of your complaint in the order in which they happened.

7. Please describe any action taken to resolve this matter prior to contacting the Board.

8. Do you have any complaint-related contracts, bills, receipts, canceled checks, correspondence or any other documents you feel are related to your complaint? Yes No

If the answer to question 8 above is "Yes," you will be required to forward readable copies of any complaint-related contracts, bills, receipts, canceled checks, correspondence or any other documents relating to your complaint to the Division of Consumer Affairs, State Board of Medical Examiners, P.O. Box 183, Trenton, New Jersey 08625-0183 . The Division will not initiate an investigation of your complaint until it has received legible copies of all of the documents you intend to submit as part of the evidence to support your complaint. Due to the fact that your name will be used as your case identifier, please be sure to write your name in the upper left-hand corner of every document that you submit to the Division of Consumer Affairs. Reminder: Retain the original document(s) and send only photostats of these papers.

9. I am authorized to consent to the release of the patient records and hereby authorize the release of information and copies of the patient records of . Yes No

By submitting this complaint form, I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. In addition, I authorize the New Jersey Division of Consumer Affairs to send this complaint form to the company or to interested parties and to use the information in any way that is necessary.


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