Complaint Form

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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 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.

The complaint committee of the board or commission for all boards and commissions, with the exception of Private Investigations, first reviews complaints against a licensee, registrant or certificate holder. 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. An anonymous complaint will not be processed. Please note that a copy of this complaint will be provided to the licensee, registrant or certificate holder, 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, NMSA 1978, Sections 14-2-1 et seq., 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:(Required)

INSTRUCTIONS

Please complete this complaint form by providing as much information as possible about your complaint, including the date, time, and location of the incident. Please attach any documentation you have when you submit your complaint.
List any other people who might have information or knowledge about this matter including their contact information.
Sign the form swearing: (a) that you are the person signing the complaint; and (b) to the truthfulness of the complaint.
All images/photos submitted shall be in color.
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 here. 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.

If necessary, upload the Child Custody Evaluation Proceedings Complaint Form or the Authorization for Disclosure of Health Record Information Form here:

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 512 MB, Max. files: 2.

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 ON THIS COMPLAINT FORM MUST BE COMPLETE ANY INCOMPLETE COMPLAINT WILL BE RETURNED TO REQUEST ADDITIONAL FACTUAL INFORMATION AND/OR DOCUMENTATION TO SUPPORT THE COMPLAINT IF NEEDED

Person Filing the Complaint

Complainant Name:(Required)

First Last

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Email:(Required)

Patient/Consumer Information (If different than above)

Relationship to Patient/Consumer:

Patient/Consumer Name:

First Last

Mailing Address:

Street Address Address Line 2 City State ZIP Code

Phone Number:

Email Address:

Name of Licensed Individual Against Whom the Complaint is Filed

Respondent Name:(Required)

First Last

If known, License, Registration or Certification Number:

Name of Business, if any:

Street Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number:(Required)

Email Address:(Required)

Nature of Complaint (check all that apply)(Required)

If Other, Please Explain:

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

Yes

(Please note that in some instances, a case may not proceed to prosecution without witness testimony.)

STATEMENT OF COMPLAINT

Date Incident Occurred:(Required)

Time Incident Occurred:(Required)

Location Incident Occurred:(Required)

Please list any evidence or supporting documentation you have available and will provide to the Board or Commission. Such documentation may include receipts, contracts, photographs, police reports, etc.:

Upload any evidence or supporting documentation you have available and will provide to the Board or Commission. Such documentation may include receipts, contracts, photographs, police reports, etc.:

Drop files here or

Accepted file types: jpg, png, pdf, docx, doc, mov, mp4, Max. file size: 512 MB.

Witness Information (Please use additional sheet if needed to list all witnesses and contact information):

Witness Name:

First Last

Contact Number:

Email Address:

Witness Name:

First Last

Contact Number:

Email Address:

Please use the following input if needed to list any other witnesses and contact information

Please describe the incident in detail(Required)

Signature(Required)

I affirm, under penalty of perjury that I am the person submitting this complaint, and that the information I provided above is true and complete to the best of my knowledge. I will make myself available as a witness should this complaint result in an administrative hearing.

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