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.

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:
Home Phone:  Cell Phone:  Work Phone: 
 

Section 2 - RESIDENT/PATIENT INFORMATION

Section 3 - GUARDIAN/RESIDENT REPRESENTATIVE INFORMATION

Section 4 - 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. 

 

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