Public Complaint Form - Nevada State Board of Optometry

NEVADA STATE BOARD OF OPTOMETRY

Post Office Box 1824
Carson City, Nevada 89702
Telephone: (775) 883-8367
Facsimile: (775)305-0105
E-Mail: admin@nvoptometry.org

COMPLAINT AGAINST A LICENSED OPTOMETRIST

Individual filing Complaint

Complainant(s)*

Mailing Address*

Daytime Phone*

Email*

Optometrist/Subject of Investigation/ Respondent*

Address*

City*

Phone*

D/B/A*

(Doing Business As)

Date(s) of Incident*

What law(s) in NRS Chapter 636 or NAC 636, or others, do you believe were violated?*

You must state the facts underlying your complaint with particularity and offer a statute or regulation that you feel has been violated. You must also provide a minimum level of credible evidence to support your claims, or they will be rejected as having failed to meet the minimum standard of proof.

Summary of Issues: (Please attach additional pages as needed and a copy of any evidence supporting your claims)*

Did you contact the Optometrist or the office they practice at regarding this complaint?*

Did the Optometrist or the office respond?*

Were there any witnesses to the incident? If so, Please provide name(s), address(es), and phone number(s)*

What would you consider a satisfactory resolution to this Complaint?*

Name, address, and phone number of any consulting or subsequent Doctor treating the issue*

If a formal charge is filed as a result of this Complaint, are you willing to testify under oath at a public hearing?

I authorize the Nevada State Board of Optometry to provide a copy of this Complaint to the subject of this Complaint and to obtain a copy of any of my patient records in the Doctor’s possession.

I,

being first duly sworn, deposes and states: I have read the foregoing Complaint and know the contents thereof; that the contents are true of my own knowledge, except as to those matters stated upon information and belief, and as to those matters I believe them to be true.

Attach Documents

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By submitting this information and checking this box, I affirm that each document is complete and correct and that all information contained in this submission is true under the pains and penalties of perjury and the requirements of NRS Chapter 636 and NAC Chapter 636 and Nevada law generally.I also acknowledge that if I have directed or authorized a person to complete or submit this information on my behalf, I, the Complainant, am fully responsible for the content of the submission.

Name*

First

Date*

Comments

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I have read all questions, answers and statements and know the contents thereof. I hereby certify, under penalty of perjury, that the information furnished in this Complaint is true, accurate and correct.