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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOVF
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State of Nevada
Office of the Attorney General
Consumer Complaint Form
2020
If you have a life-threatening emergency or are in immediate danger, please contact local law
enforcement by dialing 911 on your telephone or cellular phone. The information you provide
on this form may be used to help us investigate violations of state laws therefore it is important
to complete all required fields. The length of this process can vary depending on the
circumstances and information you provide. Please note: The Attorney General cannot provide
you with legal advice or represent you in personal legal actions. If you cannot afford a private
attorney, you may consider contacting your local legal aid office.
If you are not filing a complaint against a specific individual, business or agency use the link on
the main Complaints page to send inquiries and/or express your concerns to this office.
No e-mail address? Call (775) 684-1128 or (702) 486-3420 for a CSU
Representative
For Printable Consumer Complaint Form, follow this link to the main Complaints page. You may also
contact us using the Inquiry link to send us an electronic request for a complaint form to be mailed to
you by simply providing your name and complete mailing address.
Please Enter Your Email Address * 1.
[email protected]
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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Verify Your Email Address - Please note a valid email address is needed in order to
receive an email notification for receipt of your complaint and to attach
supporting documents. *
2.
[email protected]
Demographics - Optional Information
To better serve our constituents, please select all that apply to you.3.
Person with Disability
Medicaid Recipient
Veteran
Current active service member or immediate family
English is a Second Language
Over the Age of 60
Have you previously filed a complaint regarding your concern with our office? * 4.
Yes
No
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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Section 1: Your Contact Information
Enter your contact information in the required fields.
Prefix (select one): * 5.
Mr.
Ms.
Dr.
Other
First Name * 6.
Elizabeth
Middle Name7.
Kathleen
Last Name * 8.
Hammack
Are You Submitting This Complaint Anonymously? * 9.
Yes
No
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOVF
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Is This a Whistleblower Complaint? * 10.
Yes
No
Your Organization or Company Name if filing on behalf of your Organization or
Company:
11.
Enter your answer
Address (or P.O. Box) * 12.
784 Valley Rise Drive
City * 13.
Henderson
State * 14.
NV - Nevada
AL - Alabama
AK - Alaska
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOVF
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CO - Colorado
CT - Connecticut
DE - Delaware
FL - Florida
GA - Georgia
GU - Guam
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MP - Northern Mariana Islands
MT - Montana
NE - Nebraska
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOVF
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NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
VI - U.S. Virgin Islands
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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Outside the U.S.
Zip Code * 15.
89052
Best Phone Number to Contact You: * 16.
702-960-9347
Other Phone Number (Home, Mobile, Work, etc...)17.
Enter your answer
Preferred Language: * 18.
English
Spanish
Tagalog
American Sign Language (ASL)
Chinese (Cantonese or Mandarin)
Korean
Vietnamese
Amharic
Arabic
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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Farsi
French
German
Portuguese
Japanese
Other:
Section 2: Reason for Complaint
In this section choose the reason you are requesting an inquiry from the following.
Type of Complaint (choose one): * 19.
CONSUMER/FINANCIAL FRAUD
HIGH TECH CRIMES
HUMAN TRAFFICKING
INSURANCE FRAUD
MEDICAID FRAUD
MISSING CHILDREN
MORTGAGE FRAUD
OPEN MEETING LAW
OPIOID VIOLATION
TICKET SALES / TICKET RESELLERS
WORKERS COMPENSATION FRAUD
PUBLIC INTEGRITY
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOVF
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OTHER (Indicate Topic):
Section 3: Contact Information for Individual / Business / Agency of
Potential Offender
Enter contact information for the individual, business, or agency your complaint is against.
Do not re-enter your contact information in this section. Select "Unknown" if you do not know the
identity of the individual, business or agency. Provide as much information as possible. Please enter
information for any and all of the these.
Who Is Your Complaint Against? * 20.
Individual
Business
Agency
Unknown
Name of Individual, If Known.21.
Doctor Fermin Leguen - District Health Officer
Additional Contact for Individual / Business / Agency, If Applicable.22.
Enter your answer
Address of Individual / Business / Agency, If Known.23.
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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280 S Decatur Avenue
City of Individual / Business / Agency, If Known.24.
Las Vegas
State of Where Individual / Business / Agency is Located, If Known.25.
NV - Nevada
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
12/18/21, 10:09 PM
State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOV
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KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
12/18/21, 10:09 PM
State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOV
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SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Outside the U.S. / OTHER
Zip Code of Individual / Business / Agency, If Known.26.
89107
Phone Numbers of Individual / Business / Agency, If Known.27.
702-759-1000
Email Addresses of Individual / Business / Agency, If Known.28.
Enter your answer
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
https://forms.office.com/Pages/ResponsePage.aspx?id=5kCj5J64aE6OqhVE0nA5gCJ94DRc5JVMolaLrIFlUBlUMjQwV1YxMlExV08yNDRYODBOV
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Website Addresses of Individual / Business / Agency, If Known.29.
https://www.southernnevadahealthdistrict.org/about-us/board-of-health/district-health-officer/
Social Media Accounts of Individual / Business / Agency, If Known. (Facebook,
Twitter, WhatsApp, Instagram, etc.)
30.
https://www.linkedin.com/in/fermin-leguen-70762395/
Date Alleged Violation Occurred (on or about): * 31.
12/3/2021
Was a Contract Signed? If You Select Yes, Please Include a Copy of the Contract. * 32.
Yes
No
Have You Contacted Another Agency for Assistance? * 33.
Yes
No
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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Have You Consulted With or Hired an Attorney? * 34.
Yes
No
Is a Court Action Pending? * 35.
Yes
No
Did You Make Any Payments to the Individual or Business? * 36.
Yes
No
Even If You Did Not Make Payments, How Much Were You Asked to Pay? * 37.
0
Section 4: Describe Alleged Incident
Description of complaint is limited to the space provided below. Please be as accurate and concise as
possible. The Attorney General’s office may contact you if additional information is needed.
Describe the Activities, Events, Concerns, or Issues That Led You to File a
Complaint: *
38.
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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NRS 239.320  Injury to, concealment or falsification of records or papers by public
officer.  An officer who mutilates, destroys, conceals, erases, obliterates or falsifies any record
or paper appertaining to his or her office, is guilty of a category C felony and shall be punished
as provided in NRS 193.130.
[Part 1911 C&P § 80; RL § 6345; NCL § 10029] — (NRS A 1979, 1463; 1995, 1264)
Section 5: Evidence
Describe any relevant documents, agreements/contracts, correspondence, or receipts that support your
complaint. Copy both sides of any canceled checks that pertain to this complaint. After complaint is
submitted you will receive a notification email of receipt from our office where you may attach your
supporting documents. Please provide clear and readable copies. You may upload photographs and/or
scans of your documents (.jpeg, .pdf, .ping, .tif)
Enter document names below.39.
District health officer report to Nevada State Board of Health Members December 3, 2021
Section 6: Witnesses
List any known witnesses or victims. Please provide names with addresses, phone numbers, email
addresses, and/or social or website information.
Witnesses / Victims40.
State of Nevada residents
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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Section 7: Additional Comments
What are you hoping the Attorney General’s office can do for you?41.
Criminally prosecute this doctor for violating Nevada Law
NRS 239.320  Injury to, concealment or falsification of records or papers by public
officer.  An officer who mutilates, destroys, conceals, erases, obliterates or falsifies any record
or paper appertaining to his or her office, is guilty of a category C felony and shall be punished
as provided in NRS 193.130.
[Part 1911 C&P § 80; RL § 6345; NCL § 10029] — (NRS A 1979, 1463; 1995, 1264)
Section 8: Signature and Acknowledgment
The Attorney General’s Office will not process any unsigned, incomplete or illegible complaint forms.
I understand that the Attorney General is not my private attorney but strives to
protect the public in part through enforcement of laws prohibiting fraudulent,
deceptive, or unfair business practices. I understand that the Attorney General is
prohibited by law from representing private citizens and does not seek refunds or
other legal remedies on their behalf. I am filing this complaint to notify the
Attorney General’s Office of the activities of a particular business, individual, or
agency. I understand that the information obtained in this complaint may be used
to establish violations of Nevada law in both private and public enforcement
actions and I agree to cooperate as a witness if required to do so. I understand
that in order to assist in resolution of my complaint, the Attorney General may
need to send a copy of this complaint form and any supporting documentation or
correspondence to the business, individual, or agency about whom I am
complaining, or another federal, state, or local agency, and I authorize this
dissemination. I understand that this complaint may be treated as a public record
under Nevada's Public Records Act and as such, limited information may also be
released or provided to the public subject to any confidentiality requirements for
personal privacy information and law enforcement sensitive information. *
42.
Yes
No
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State of Nevada Office of the Attorney General Consumer Complaint Form 2020
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I certify under penalty of perjury that the information provided on this form is true
and correct to the best of my knowledge. *
43.
Yes
No
Digital Signature - Typing full name is legally binding. * 44.
Elizabeth Hammack