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
Complaint Process
Please be assured that the allegations contained in your complaint will be fully reviewed. Because of the complex nature
and number of complaints received by the Board of Medical Examiners, we cannot give you any specific date by which that
review will be completed. To properly evaluate a complaint, the Board will need to obtain a response from the physician
first. Thereafter, an investigation may be necessary. We may also need to obtain additional information from you. Your
cooperation, patience and understanding are appreciated.
If you have not received a response an acknowledgement of your complaint from the Board within 60
days, you may contact the office by phone at (609) 826-7100 or by E-mail at: bmepatientadvocate@dca.lps.state.nj.us.
Please recognize that the Board has jurisdiction to take action against licensees only if their conduct violates the Medical
Practice Act. Very often patients may be dissatisfied with the care that they have received, but the physician’s conduct does
not violate any specific statute or rule and so cannot be the basis for the imposition of discipline. You should also be aware
that even if the Board determines that the statutory threshold for discipline has not been met, a patient who has been harmed
may still be able to pursue a private cause of action, if a lawsuit is filed within the time allowed by law. If you believe that
you may have a private cause of action, you should consult with an attorney to assure that your rights are protected.
While we cannot tell you when the Board’s inquiry may be completed, we will advise you in writing when a final
determination has been made. Thank you for bringing this matter to the attention of the Board. We hope to be able to address
your concerns as soon as possible.
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: _________________________
3. Please provide the following information about any other practitioner or licensee involved in the matter about which
you are filing a complaint.
Name: ________________________________________________________________________________________
Title: _________________________________________ License number: _________________________________
Address: ______________________________________________________________________________________
Telephone number: ________________________________
Name: ________________________________________________________________________________________
Title: _________________________________________ License number: _________________________________
Address: ______________________________________________________________________________________
Telephone number: ________________________________
4. Please provide the following about anyone who was a witness to the matter about which you are filing a complaint.
Name: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
Daytime telephone number: _______________________ Evening telephone number: ________________________
Name: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
Daytime telephone number: _______________________ Evening telephone number: ________________________
5. What is the nature of the complaint? (Please check all that apply and provide any additional comments on a separate
sheet of paper.)
Administrative/Recordkeeping Advertising Fees/Billing Practices
Fraud Incompetence Insurance Fraud
Professional/Occupational Misconduct Sexual Misconduct Substance Abuse/Impairment
Unlicensed Practice 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. Please print clearly. You may use
additional sheets of paper if they are needed.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
(include area code) (include area code)
(include area code) (include area code)
Street address City State ZIP code
(include area code)
Street address City State ZIP code
(include area code)
Street address City State ZIP code
Street address City State ZIP code
7. Please describe any action taken to resolve this matter prior to contacting the Board. Please print clearly. You may use
additional sheets of paper if they are needed.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
All complaints must be accompanied by readable copies (NO ORIGINALS) of any complaint-related contracts, bills,
receipts, canceled checks, correspondence or any other documents you feel are related to your complaint.
8. I certify that the statements made by me in this complaint are true and any documents attached are true copies. I am
aware that if any statements made by me are willfully false, I am subject to punishment.
_______________________________________________ ____________________
Signature* Date
Return to:
Division of Consumer Affairs
State Board of Medical Examiners
P.O. Box 183
Trenton, NJ 08625
* This certification must be signed by the person who has completed this form.
2/8/05
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signature
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