New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
140 East Front Street, 2nd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
(include area code) (include area code)
Street address City State ZIP code
Month Day Year
(include area code)
(include area code) (include area code)
Complaint Form
Please print clearly.
Please be advised that this complaint form, along with any documents you may have appended to the form, 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 individuals 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.
Consumer Information Complaint Reported Against
NAME: _________________________________________ NAME: _________________________________________
ADDRESS: ______________________________________ BUSINESS NAME: _________________________________
CITY: __________________________________________ ADDRESS: ______________________________________
STATE: ___________________ ZIP CODE: ______________ CITY: __________________________________________
HOME TELEPHONE NUMBER: _________________________ STATE: _______________________ ZIP CODE: __________
WORK TELEPHONE NUMBER: ________________________ TELEPHONE NUMBER: ______________________________
FAX NUMBER: ___________________________________ TITLE: _________________________________________
E-MAIL ADDRESS: ________________________________ LICENSE NUMBER (IF KNOWN): _______________________
DAT E: _________________________________________ DATES OF TREATMENT/SERVICE:
FROM: ___________________ TO: __________________
1. What is the relationship between the complainant and the consumer or patient?
Self Spouse
Parent Son/Daughter
Friend Brother/Sister
Legal Guardian 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: ____________________
Address: ______________________________________________________________________________________
Home telephone number: ___________________________ Work telephone number: _________________________
