HEALTH FACILITY COMPLAINT FORM

Complete the information on all sections of this form. If you need help or have questions about this form, please call 800-882-6006.

INFORMATION ABOUT PERSON FILING THE COMPLAINT

If you wish to remain anonymous do not complete this section. If anonymous, our office will not be able to contact you to obtain additional information or reach you to notify you of the results of the investigation.

 

Daytime Phone #:    Work      Work



RESIDENT/PATIENT INFORMATION

 and/or Age:

FACILITY/AGENCY INFORMATION

Surgery center  

State: MI


INFORMATION ABOUT YOUR COMPLAINT
 


The Department will not disclose the name of a complainant or the resident named in the complaint during a nursing home investigation without written consent. However, the investigation can proceed more quickly if the complaint can be discussed at the time of the investigation.

Do you give permission for the resident's name to be released to discuss the complaint?







  Yes No


  By checking the box and typing my name below, I am electronically signing this form.

 

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All Health Care Facilities that are state licensed and/or federally certified providers are required to post the name, title, location, and telephone number of staff responsible for receiving complaints. You may wish to contact the provider representative or administrator before filing this complaint.

The Department will send an acknowledgement letter upon receipt of the complaint and will send an additional letter after the investigation is completed to notify the complainant regarding the results of the investigation.

Other agencies that help citizens with complaints are:

The State Long-Term Care Ombudsman
The ombudsman will help identify, investigate and resolve complaints of residents of licensed long-term care facilities through its network of local ombudsmen.
Call: 866-485-9393 (toll-free)

Department of Attorney General (AG)
The AG investigates elder abuse and Medicaid fraud.
Call: 800-242-2873

Michigan Protection & Advocacy Service (MPAS)
MPAS can help you file a complaint or investigate an abuse/neglect allegation.
Call: 800-288-5923 or 517-487-1755

LARA Bureau of Professional Licensing - Licensed Health Professionals
The Bureau also handles complaints against licensed health professionals including physicians, nurses, etc.

LARA Bureau of Community and Health Systems
The Bureau handles complaints against a state licensed adult foster care, home for the aged, child care center or home, or adult foster care or child camp.

The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc. under the Americans with Disability Act, you may make your needs known to this agency.