COMPLAINT FORM

Boards and Commissions Division

2550 Cerrillos Road | P.O. Box 25101

Santa Fe, NM 87504

(505) 476-4622 | rld.state.nm.us

OFFICIAL USE ONLY

COMPLAINT #

STATE OF NEW MEXICO

MICHELLE LUJAN GRISHAM, GOVERNOR

Linda M. Trujillo, Superintendent

John Blair, Deputy Superintendent

COMPLAINT FORM

When you (“Complainant”) file a complaint against a licensed individual, please be advised that the licensing board’s or

commission’s jurisdiction is limited by statute. Jurisdiction is usually limited to violations of the licensing statute and administrative

rules, and may result in disciplinary action against the licensee. The board or commission cannot guarantee refunds of money paid

by a Complainant to a licensee, nor can the board or commission ensure the outcome a Complainant may desire. Financial or billing

disputes are outside the jurisdiction of a board or commission, and a Complainant is encouraged to resolve such disputes with a

licensee prior to filing a complaint unless the allegations consist of a pattern of unethical/fraudulent billing by the licensee. Boards

and commissions are tasked with the protection of the public welfare as a whole; they do not represent the Complainant as an

advocate or in an attorney-client relationship.

Complaints against a licensee are first reviewed by the complaint committee of the board or commission. An anonymous complaint,

or a complaint filed by a person without first-hand knowledge of the allegations, will be reviewed by the complaint committee to

determine whether to recommend proceeding forward with the complaint process. In some instances, anonymous complaints may

be impossible to investigate and prosecute.

Please note that a copy of this complaint will be provided to the licensee along with a request for a response to the allegations. All

information included in this complaint, including supporting documentation, may be subject to inspection pursuant to the Inspection

of Public Records Act, unless excepted from release under the Act or other state or federal law.

_____________________________________________________________________________________________________________________________________________________________________________

Please check the box for the applicable board or commission you are filing your complaint with:

SANTA FE – Mail your complaint to the address listed above.

Acupuncture & Oriental Medicine Funeral Services Podiatry

Athletic Commission Landscape Architects Private Investigation

Athletic Trainers Massage Therapy Psychologists*

Barbers & Cosmetologists Nursing Home Administrators Real Estate Appraisers

Body Art Nutrition and Dietetics Respiratory Care

Chiropractic Occupational Therapy Signed Language Interpreting

Counseling & Therapy Optometry Social Work

Dental Health Care Osteopathic Medicine Speech Language Pathology, Audiology

Interior Designers Physical Therapy & Hearing Aid Dispensing Practices

INSTRUCTIONS

1. Complete this complaint form by providing as much information as possible about your complaint.

2. List any other people who might have information or knowledge about this matter including their contact information.

3. Sign the form swearing to its truthfulness and if required in front of a notary public.

4. Forms must be legibly printed or typed and then printed on 8-½”x11” paper or they will be returned. Submit the completed

form and any supporting documentation to the Board Office at the Santa Fe address noted above or at the Albuquerque address

for the Public Accountancy Board or Real Estate Commission.

5. All images/photos submitted shall be in color.

6. If you are filing a complaint against a health care practitioner your medical records may be required to process your complaint.

Please submit an Authorization for Disclosure of Health Record Information form which can be downloaded from the Board’s

or Commission’s website. You will receive an acknowledgement letter confirming receipt of your complaint.

*If you are filing a complaint with the New Mexico State Board of Psychologist Examiners regarding a Child Custody Evaluation,

you must complete the Child Custody Evaluation Proceedings Complaint Form in addition to this form. The form can be

downloaded from the Board’s website.

Please note that a copy of this complaint will be provided to the licensee along with a request for a response to the

allegations.

Boards and Commissions Division

P.O. Box 25101 | Santa Fe, NM 87504

(505) 476-4622 | rld.state.nm.us

OFFICIAL USE ONLY

COMPLAINT #

COMPLAINT FORM

Person Filing the Complaint

Name:

Mailing Address:

City: State: Zip:

Contact Number:

Email Address:

Patient/Consumer Information (If different than above

Relationship to Patient/Consumer:

Patient/Consumer Name:

Mailing Address:

City: State: Zip:

Contact Number: Email Address:

Name of Licensed Individual Against Whom the Complaint is Filed

Name:

If known, License #:

Name of Business:

Street Address:

City: State: Zip:

Phone #:

Nature of Complaint (check all that apply)

Quality of Care or Service Sanitation Violation

Inappropriate Prescribing Excessive Tests or Treatment

Misdiagnosis or Failure to Diagnose Sexual Misconduct

Failure to Release Records Substance Abuse

Insurance Fraud Impairment/Medical Condition

Advertising Violation Patient Abandonment/Neglect

Violation of Confidentiality Unlicensed Activity

Code of Conduct/Ethics

Other (Please Explain)

In the event that this complaint is presented in a formal administrative hearing, are you willing to testify as a witness?

Yes No (Please note that in some instances, a case may not proceed to prosecution without witness testimony.)

Other Witness Information:

Name:

Contact Number: Email Address:

Name:

Contact Number: Email Address: