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.

Note: If you wish to remain anonymous, skip to Section 2 - RESIDENT/PATIENT INFORMATION 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.

Section 1 - INFORMATION ABOUT PERSON FILING THE COMPLAINT

Relationship to Patient/Resident:
Work Phone:   Home Phone:   Cell Phone:
Best number to reach you between 8a-5p?    
         

Section 2 - RESIDENT / PATIENT INFORMATION

   

       
 

Section 3 - GUARDIAN / RESIDENT REPRESENTATIVE INFORMATION

 

Work Phone:   Home Phone:  Cell Phone:

Best number to reach you between 8a-5p? 

Section 4 - FACILITY / AGENCY INFORMATION

Facility/Agency Type:







*Other federally certified providers include dialysis centers, rural health clinics, outpatient physical therapy (OPT) providers, comprehensive outpatient rehab facilities (CORF), portable X-ray providers, and providers offering laboratory services. 

Facility/Agency Name:

Facility/Agency Address:

City:    State: MI

Zip Code:

Section 5 - 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 this box and typing my name below, I am electronically signing this form.

      

    

* Spam Block: (What's this?)
     


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 long term care ombudsman program can help you file a complaint or investigate your concerns at licensed long-term care facilities.
Call: 866-485-9393 (toll-free)
Email: MLTCOP@meji.org

Department of Attorney General (AG)
The AG investigates elder abuse and Medicaid fraud.
Fax: 517-241-6515 or 517-241-1029
Mail: P.O. Box 30218, Lansing, MI 48909

Michigan Protection & Advocacy Service (MPAS)
MPAS can help you file a complaint or investigate an abuse/neglect allegation.
Call: 800-288-5923
Fax: 517-487-0827

LARA Bureau of Professional Licensing - Licensed Health Professionals
The Bureau also handles complaints against licensed health professionals including physicians, nurses, etc.
Call: 517-373-9196
Fax: 517-241-2389

Children and Adult Licensing
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.
Call: 866-856-0126
Fax: 517-284-9739
Email: bcalonlinecomplaints@michigan.gov

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.