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