Complaint Form
1. The North Carolina State Board of Examiners in Optometry (“the Board”) licenses and regulates only optometrists, whose professional designation is “O.D.” For the purposes of this form they are referred to as “licensees” of the Board.

2. Complaints received which involve non-licensees (such as physicians (“M.D.”), opticians, hospitals, etc.) will be referred by the Board to what we understand to be the appropriate state agency, with a copy of such referral sent to you.

3. This complaint form should be filled out by the patient or the patient’s legal representative, unless the complaint is being submitted by another health care professional.

4. This complaint form may be filled out on-line and submitted electronically, along with any documents you wish to submit in support of the complaint, or you may print the form out, complete it, and submit it along with any supporting documents by mailing or otherwise delivering them to the Board at the address provided above. To print this form, please return to the previous page and select the "PDF: version instead of "On-line".

5. The patient or the patient’s authorized legal representative should also complete the release of medical record authorization form so that any necessary records can be obtained to complete the review of the complaint. (See attached Records Release Authorization and Certification form.)

6. A copy of the complaint will be provided to the licensee against whom the complaint is being made. The licensee will be required to review the complaint and to provide a written response to the Board; that response may be (upon request) provided to you.

7. Provide the information requested in each section of the complaint form. If you have a complaint against more
than one licensee, please provide a separate form for each licensee about whom you are complaining.

8. The Board does not have the authority to award monetary damages of any kind or to require that a licensee refund fees to you or pay for any re-treatment.

9. The Board cannot provide legal advice to you.

10. If the Board determines that the substance of your complaint is that the licensee did not provide the required quality of care, the Board may ask that you undergo an independent examination. Such examination will be provided at no cost to you by another licensee of the Board and will be scheduled to minimize any inconvenience on your part.

11. You must be willing to testify under oath to the substance of your complaint, either in a deposition or a formal hearing, or both.

12. Remember to retain a copy of your completed complaint form as well as any documents or other information you
submit to the Board; none of the materials you provide to the Board will be returned to you.

13. Generally once a complaint is submitted to the Board it cannot be withdrawn and the Board will continue with its investigation and, potentially, disciplinary action against the licensee.

14. Please note that the length of time it will take to complete the investigation of your complaint can vary from a few weeks to many months, depending in part on the nature of the allegations, the number of persons who may need to be interviewed, the need to obtain records from the O.D. at issue and any other medical care providers, and the number of investigations the Board currently may have open.

15. If you have questions regarding how to fill out or submit your complaint form you may contact the Board Staff via email (complaints@ncoptometry.org) or phone at 1-800-426-4457 or 910-285-3160.
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