Fillable COMPLAINT FORM 9600 Gateway Drive, Reno, NV 89521 (State of Nevada, Department of Information Technology)

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COMPLAINT FORM 9600 Gateway Drive, Reno, NV 89521 (State of Nevada, Department of Information Technology)

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The COMPLAINT FORM 9600 Gateway Drive, Reno, NV 89521 (State of Nevada, Department of Information Technology) form is 2 pages long and contains:

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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1
COMPLAINT FORM
You may use this form to provide your complaint information and summary. Be as concise as
possible. You may mail or fax this completed form, to the Board at the above
address or fax number, or you may e-mail this form to Administrative Assistant, Norma Perkins
at nperkins@medboard.nv.gov. You will receive a written response from the Board once your
complaint has been reviewed and processed.
Your Name: Gender: ____ M / ____ F
Phone Number(s):
Mailing Address:
City: State: Zip:
Patient Name: Gender: ____ M / ____ F
Patient Date of Birth:
Physician(s), Physician Assistant(s), Practitioner(s) of Respiratory Care, Perfusionists named
in Complaint:
1) Name:
Address:
City: State: Zip:
Phone Number(s):
2) Name:
Address:
City: State: Zip:
Phone Number(s):
3) Name:
Address:
City: State: Zip:
Phone Number(s):
9600 Gateway Drive, Reno, NV 89521
Phone: In Reno/Sparks/Carson City: (775) 688-2559
(If calling from any other area of Nevada, call the Board's in-state, toll-free number:
888-890-8210) Fax: (775) 688-2553
2
Date(s) of Occurrence:
Treatment Received At (please check the following that apply, and include 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
By checking this box, I hereby attest that the information contained in this Complaint is true
and correct to the best of my knowledge and belief.
Date:
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COMPLAINT FORM 9600 Gateway Drive, Reno, NV 89521 (State of Nevada, Department of Information Technology)

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Completed 20 August 2021

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